Organization
[November 30, 2022 3:19 PM]
Ontario Medical Association (OMA)
Response in PDF format.
Member of the public
[November 28, 2022 11:54 PM]
As a member of the public, my appreciation goes to each member of the College of Physicians and Surgeons for their willingness and courage to serve the public in the most profound aspects of life and death.

As I read through the “Professional Obligations and Human Rights” and the companion resource, “Advise to the Profession: Professional Obligations and Human Rights”, I found myself drawing on the Professional Rules of Conduct of my own profession to make sense and take measure of the proposed changes being considered. I soon realized comparisons fail due to the unique challenges of the health care profession.

Like any profession, yours is at the serve of the public. That the interests of the members of a profession are secondary to those of the public seems appropriate on the surface. That is the premise of these two documents: that patient rights require protection. But this subtly implies that patient rights have been abused. I would have thought such a suggestion would be objectionable to the College and its members. This undermines the ancient trust existing between doctors and society.

With respect to sections contained in Professional Obligations and Human Rights, to me, they display an unjust prejudicial distinction (and lack of respect) towards certain members which I find disturbing and alarming. Targeting faith-based groups as this document and its companion document, does damage to reputations of its members, the profession itself as well as subtly undermining public confidence.
Member of the public
[November 28, 2022 11:16 PM]
I am writing to provide feedback on the above mentioned draft policy and advice documents.
 
The College of Physicians and Surgeons of Ontario [CPSO] draft policies appear to normalize MAID as a standard treatment that should be offered by health care professionals to all people who might qualify. The Draft Medical Assistance in Dying Policy, and the Draft Human Rights in the Provision of Health Services Policy fail to clearly identify the need to protect disabled people without discrimination against premature death and introduce some requirements that appear to create a tension with physicians‘ duties related to helping their patients avoid premature death, and this on a non-discriminatory basis. I urge the CPSO to revise the draft policies to address these concerns. The policies should at a minimum recognize and address the tension between providing access to MAID and the need to protect against premature death on a non-discriminatory basis.
 
Neither the Supreme Court, nor federal law, nor any other jurisdiction in the world, treats MAID as a standard medical procedure. The Supreme Court emphasized in Carter that MAID should only be permitted in exceptional circumstances, and that the practice should be surrounded by the strictest safeguards. We see that also reflected in our current law—albeit arguably insufficiently—to the extent that the law introduces additional requirements, over and beyond those that exist in medical care. Assisting someone to die remains a criminal code offense, punishable by imprisonment, and MAID is carved out as an exemption to this prohibition, in defined circumstances. The CPSO policies should emphasize that suicide prevention remains a key obligation of physicians, which applies regardless of whether a patient has a disability. The policies should remind physicians that direct involvement in termination of life and counselling to support suicide remain prohibited in the criminal code. This emphasis is important, to avoid that ending of life is normalized as standard treatment. It is particularly important now that MAID has been legalized outside the end-of-life context.
 
I further want to express specific concerns about the following:
 
1) The CPSO Draft Advice to the Profession suggests that there is a duty to bring up MAID as part of the informed consent process. Th Draft Document has the following provision that refers to and appears to endorse a Canadian Association of MAID Assessors and Providers [CAMAP] policy:
 
“Physicians will have to use their professional judgment to determine if, when, and how to discuss MAID with their patients. The Canadian Association of MAID Assessors and Providers (CAMAP) has a clinical guidance document on Bringing up MAID as a clinical care option, which includes the following:
  • The appropriate timing of discussions regarding MAID is determined by the clinical context and the specific circumstances of the patient.
  • When discussing MAID as a treatment option, be aware of the physician-patient power dynamic and ensure MAID is presented as one of the treatment options, and not as a coercive recommendation to pursue that option.
  • It is important to approach discussions regarding MAID from a place of respect and trust and allow for sufficient time to have such sensitive conversations.”
The CAMAP policy also explicitly states, however, that MAID should be introduced to everyone who ‘might qualify’. If one applies this policy, a capable disabled person with irreversible decline of capability who consults a health care provider to help address a medical condition that might create serious suffering, would have to be told by the provider that MAID is an option. That seems reckless and constitutes a violation of the standard of care. Decisions to bring it up will be influenced by health care providers’ potential ableist perceptions of the quality of life of disabled persons. It will harm the doctor-patient relation to introduce MAID in this context and can be inappropriately inducive. Considering the power imbalance of the health care provider-patient relation, and the context in which this issue will come up, it is in my opinion inappropriate to indirectly endorse the CAMAP policy. On the contrary, the CPSO should explicitly state that health care providers should NOT bring up MAID unless explicitly asked. This should be the presumption, particularly outside the end-of-life context, and clearly also in relation to patients who struggle with mental health issues or who may be suicidal.
 
Other jurisdictions which have recently introduced Assisted Suicide for persons with a terminal illness diagnosis (e.g. New Zealand and Victoria (Australia)) explicitly prohibit physicians from introducing MAID to patients without being asked about it. In Belgium & The Netherlands, the law does not explicitly prohibit physicians from bringing it up, but it is emphasized that the initiative has to come from the patient. Moreover, in those jurisdictions, physicians cannot offer it if other treatment options are available that have not yet been tried. Physicians need to agree in those jurisdictions that there are no other options left to address the unresolved suffering. Offering it as part of an initial informed consent process to a patient who ‘might qualify’ seems thereby inconceivable. I urge the CPSO to explore how to introduce an explicit prohibition for health care providers to bring up MAID without being invited by the patient to talk about it. This is particularly important outside of the end-of-life context.
 
2) The CPSO Draft Policy on Human Rights in the Provision of Health Services
  • The ‘effective referral’ provisions will, according to this draft policy, also be applicable outside the end-of-life context. This, combined with the issues raised above, is problematic. The CPSO invokes the Ontario Court of Appeal decision in Christian Medical and Dental Society of Canada v. College of Physicians and Surgeons of Ontario, 2019 ONCA 393, but this decision dealt with MAID practice in a more restrictive end-of-life context under the previous law. Applying this obligation outside the end-of-life context brings up more significant concerns about the lack of clear standards and safeguards to determine irremediability and ‘irreversible decline of capability’.
  • Physicians who know that there are reliable treatment options for patients who may have years and decades of life left, may now be forced to accept a perhaps impulsive treatment refusal, and may feel under a professional obligation—enforceable by sanction—to refer their patient to physicians who are known to be open-ended about offering MAID, even if they themselves feel that it violates their professional duties to provide MAId in that situation. This would be the case even if they feel, in their professional opinion, that their colleagues may be too flexible about offering MAID in those circumstances. The fact that the criteria to obtain MAID are open-ended makes this a very real possibility. The CPSO guidelines may thereby result in a spiraling towards the most recklessly flexible MAID standards. This puts numerous patients are risk of premature death, particularly—but not only--in the mental health context.
  • The “effective referral” obligations under point 9 appear to create obligations that go beyond the obligations that a physician has in a normal clinical context when making a referral. Remarkably, when a physician has a conscience or religious objection, the policy appears to create a stronger duty to ensure ‘effective’ referral for conscientious objectors than the duty a physician without conscience or religious objection has.
  • With Bill C-7, there is a commitment to introduce MAID for mental illness as of March 2023. Neither the federal law, nor any existing or proposed guidelines propose further safeguards to protect persons with mental illness in the MAID context, notwithstanding significant concerns expressed by the patient and mental healthcare provider community. There is, for example, no indication as to what ‘irremediability’ means in the context of mental health, or in the context of the intersection between various disabilities and mental health. The CPSO should clarify that irremediability is a key requirement for MAID, and that this concept applies regardless of a patient’s refusal of therapy or the acceptability of a treatment option from the patient’s perspective. Of course, patients cannot be forced to undergo treatment, but the CPSO should specify that irremediability remains an independent requirement.
  • The ‘Duty to Provide Services Free from Discrimination’ (point 5) fails to mention a most important duty: the duty to protect patients against premature death, including death from suicide, without discrimination based on a protected ground. The Human Rights policy should explicitly refer to an obligation to provide equal protection against premature death of disabled persons, including by providing adequate suicide prevention.
 
The Draft Policy contains the following provision:
 
“11.When completing the medical certificate of death, physicians: a. must list the illness, disease, or disability leading to the request for MAID as the cause of death; and b. must not make any reference to MAID or the medications administered on the certificate”
  • If there ever was a justification for this practice—in my view there never was—, the justification no longer holds. Requesting physicians to invent a cause of death on a death certificate, particularly when a person who died by MAID would otherwise have lived for years or decades, is hugely problematic. It constitutes the creation of a professional obligation to falsify official forms, which is from a professional regulatory perspective deeply problematic and sets a terrible precedent.
  • This provision was in my view already problematic when MAID was restricted to a reasonable foreseeable natural death, because of the above concern, i.e. normalizing the falsification of a document. With the already broad interpretation of RFND this was also already a problem, in that a person who might have had two or three years of life left was now deemed to have died of a condition which normally does not cause death (e.g. osteoarthritis). But it becomes even more problematic when a person is not in any way otherwise approaching their natural death. It seems absurd, but also problematic from a disability rights perspective, to frame it as if persons died from a disability that does not cause death.
  • I further wonder what this may mean for statistical and research purposes, if we now start registering causes of death that are regulatory constructions and removed from reality.
4) I recommend that the CPSO introduce its own detailed quality control standards and strict oversight over the practice of MAID, as part of its MAID policy. This should include, for example, control over who is providing MAID, on what basis, and how frequently. The CPSO already engages in some control over, for example, medicine prescription practices. When it comes to a procedure that inevitably results in death, sufficient control seems so much more essential.
 
I would be happy to provide further feedback and help reflect on how the CPSO could address the discriminatory lack of protection against premature death of disabled persons in the context of the practice of MAID; how it could prohibit bringing up MAID outside well-defined circumstances, introduce better safeguards and standards, and improve regulatory oversight.
Organization
[November 28, 2022 10:11 PM]
Abortion Rights Coalition of Canada (ARCC)
Response in PDF format.
Physician (including retired)
[November 28, 2022 10:05 PM]
This new policy is frankly appalling, and would prevent me from ever being able to work in Ontario in good conscience.

It imposes unequal requirements on objecting and non-objecting physicians with regards to the provision of euthanasia and other contested services, creating a two-tier classed system where those who do not object can simply refer without further imposition, but those who believe it is not good medicine to end the lives of their patients are humiliatingly forced to not only enable their death but go through the charade of verifying they've been connected with the provider.

This is clearly discriminatory and unethical, while creating an extra imposition not required in the provision of any more typical health care services.

In short, this intentionally burdens physicians of a particular group with tyrannical, unethical, and discriminatory regulations. This will not help patients, physicians, or the health care system, but will instead further harm the provision of health care in high need areas (noting that commonly physicians with religious convictions that preclude provision of euthanasia also have inseparable convictions which motivate them to serve underserved areas or populations).

In short, this is ideological, harmful, and short-sighted, and needs to be changed.
Physician (including retired)
[November 28, 2022 9:56 PM]
In an ongoing attempt to ensure that the rights of patients are respected, the College continues to go too far with regard to its requirements for conscientious objectors. Asking those who have legitimate objections to procedures which remain controversial and which have deeply moral implications to provide referrals (or, in an emergency, the objectionable act itself) is wrong - especially given that systems are in place to make this involvement unnecessary. Furthering that requirement to ensure connection with the consulting physician is made is another step that should not be required - this is not required in other referral contexts and would seem likely to worsen the moral injury involved should an objecting physician decide to comply.

Rights of patients should absolutely be respected by us as physicians. Requiring the involvement of objecting physicians is not necessary and should not be done.
Organization
[November 28, 2022 9:37 PM]
Black Physicians' Association of Ontario (BPAO)
Response in PDF format.
Physician (including retired)
[November 28, 2022 8:13 PM]
I find the CPSO's adoption of coersive tactics enforcing deceptions and lying not grounded in Hippocratic principles, the Georgetown mantra or evidence-based medicine to be antithetical to the vocation of physician and certainly to good patient care.

After 54 years serving in all areas of family practice including palliative care, emergency medicine and the teaching of students and residents, I think the CPSO's current unconscionable mandates are leading the profession in a terrible downward course.

Of relevance, for many years I also served the CPSO as one of their contracted physicians evaluating the actions of physicians with regard to ethical and professional behavior.

Thanks for inviting comment.

Please entertain seriously changing the apparent foundational violations of our profession you may be committing.
Physician (including retired)
[November 28, 2022 8:09 PM]
There is a variety of discretion and personal judgment in medicine. Whether it be for procedure referrals, medication choice or diagnostic imaging, not every physician’s practice and referral pattern are the same. The college affords autonomy among physicians to practice sound judgment. However, with the Human Rights in the Provision of Health Services document it appears that the CPSO is attempting to impose a certain moral stance on some of the most controversial aspects of medicine and demand that physicians must refer for and/or offer those practices. I am not sure why such an aggressive stance is needed?

There are a select few issues in the medical field that have consistently, over time, caused a significant percentage of physicians (and the public) to debate and in many cases have moral distress. Chief among these are abortion and euthanasia. Both have been controversial and hotly debated for hundreds of years and both are likely to be controversial well into the future. Even in our own country MAID was illegal only a few short years ago. It has since rapidly expanded beyond where we were promised the safeguards were set (safeguards to protect the vulnerable). Thus, it is not clear why the CPSO, with this policy, would be insisting on the involvement of physicians that firmly believe that their involvement in these areas is wrong (either by personal involvement or by asking someone else to perform the activity with a referral). There are many other ways to approach this without the CPSO taking a particular moral stance and demanding many hundreds, or thousands, of physicians compromise their professional judgement.
Physician (including retired)
[November 28, 2022 7:30 PM]
A doctor with no ethical or moral compass is no benefit to anyone. Even worse, a doctor with no ethical or moral compass is a potential danger to society.

The entire medical school system is intended to select for doctors who can be conscientious individuals. We are supposed to be individuals with a strong capacity for acting in a way that is consistent with one's personal and professional ethics, while also remaining respectful of other's perspectives.

We also formally study medical ethics in school as part of our education.

The purpose of this entire system is to create doctors who can function as individuals with own own internal morality, ethics, and sense of right and wrong, while also being respectful of our patients' potential differences.

This is a delicate task which we are selected for our capacity in managing and trained to hone our skills at.

Reducing all of medical ethics to "doctors must not express any of their own ethical values to any patient at any time and must comply with all patient requests" is absolutely absurd. It makes a mockery of the complex practice of medicine and medical ethics.

Please clearly identify the specific tangible problem(s) you are attempting to remedy with this document and then consider if there is some other way to manage it that isn't already covered under your existing regulations.

For example, if you believe there is a doctor who is managing their practice in a racially insensitive or otherwise discriminatory manner, you already have regulations to sanction and suspend them, as you are aware.

Or if you would like certain services (like MAID) to operate freely without a doctor's referral so that any member of the public can ask for it, then simply allow those clinics to take patients by direct and open patient request.

I am not clear on what specific rampant issue of supposed doctor misconduct you are attempting to solve through this policy that aren't already manageable with basic steps you already have in your regulatory capacity.

Reducing the entire complex practice of medical ethics to a punchline of "keep your mouth shut even if you disagree with something and do whatever patients tell you to" and "you must forever now claim to follow only the racial/political ideology we find acceptable (within which even MLK's beliefs would be unacceptable)" is not going to help.

It is certainly not what you will find in any reasonable medical ethics text.
Organization
[November 28, 2022 6:39 PM]
Evangelical Fellowship of Canada
Response in PDF format.
Physician (including retired)
[November 28, 2022 6:06 PM]
I have a question more than a comment. Does the CPSO actually wish this process to be a consultation or is this a repeat "window dressing" so the CPSO can say that it asked for feedback when there is no apparent intention to consider the feedback.

I ask based on the Consultation in 2014 Physicians and the Ontario Human Rights Code wherein on your website it is noted 77% of 32000 respondents wished the policy to reflect that physicians should be allowed to refuse to provide a treatment on moral or religious grounds and yet the policy passed with no changes to reflect this. It is all the more interesting when it can be noted that the last 20 or so consultations on the CPSO website had on average less than 100 responses. Clearly the public and profession wished input on this matter.

I enclose the link below.
feedback.http://policyconsult.cpso.on.ca/?page_id=3403#:~:text=The%20Ontario%20Human%20Rights%20Code%20articulates%20that%20every%20Ontario%20resident,%2C%20sexual%20orientation%2C%20and%20disability.

I suppose it is up to the CPSO if it intends to actually consider the feedback this time. If it has no intention perhaps the CPSO should stop misleading the public and profession that it actually cares for our opinions and stop asking for opinions it does not wish to hear
Physician (including retired)
[November 28, 2022 5:31 PM]
Advice to the Profession, Human Rights in the Provision of Health Services.

Sadly, this document is a compilation of confused Orwellian double-speak based more on political correctness than good medical care or clarity of instruction.

For example, in line 51 -52 it says we should be aware of our own biases (and not encouraging the biases) in creating a non discriminatory office space and then in lines 176-185 says to foster them for patients. Clearly they are harmful or they are not. They can not be both. If only physicians need to be bias free then the CPSO is sanctioning creating environments for physicians where they are subject to discrimination despite saying this is unacceptable in lines 189-191. If biases are not necessarily wrong for patients, why are they wrong for physicians? If they are wrong for physicians, how can they not be wrong for patients?

In the context of effective referral, the document states it does not guarantee the patient will receive the service (lines 262-264) but then insists those physicians who have moral objections ensure they occurs (line 310 -324). Again something is either guaranteed or not. It can not have a preferential status for one group as that is overt discrimination and in this case appears to be politically motivated against those with conscientious objection. It is discrimination on two levels and totally abrogates the right of the patient to not carry through with the referral. How is this patient centred? How does this respect to the right of the patient to change their mind? How does this not become coercive to a patient who has reconsidered their choice? How can a document that purports to foster human rights, encourage open discrimination?

Lines 333- 338 ignore the fact faith based hospitals and similar institutions attract like-minded people. Their goals and ideals are clearly stated. Patients have the right to chose to attend or not attend these institutions as they would a house of worship. If they chose to seek care there then they are choosing the care model offered. They have already had informed consent as to what is offered or not. They can not expect the institution to change if they change their mind. That shows no respect to the institution which has clearly stated its purpose and care model or to the patient as it diminishes the patient's autonomy to choose where they receive care. If they change their mind, they can request a change of institution. It does not need to be required of the attending physician. The physician may facilitate it, but should not be required to do so.

The document also speaks to physicians being health advocates (lines 69-72). It encourages this as it should. It fails to speak to how we should do that. It spends far too much time outlining access to services that many find morally objectionable rather than advocating the CPSO advocate for positive health care changes auch as the "Right to palliative care" enshrined in law, that is equal to MAID services. If patients had Rights to Palliative services perhaps there would be no need of a right to MAID or onerous policies to force physicians to participate in morally objectionable procedures. Why doesn't the CPSO make an equal commitment (line 30) to ensuring patients have a right to good care, social determinants of health, access to service, goals which are easily defined rather than just trying to pursue nebulous terms of reference that they can not even clearly define.

This document needs a total re- write to eliminate its biases and contradictions. It does not provide clarity to physician or patients. It is a clear 'Fail" on the CPSO's mandate to do both.
Physician (including retired)
[November 28, 2022 5:26 PM]
Human Rights in the Provision of Health Care

This document has several flaws. It cannot clearly define its terms or reach. It is vague in some areas and over- reaching in others.

For example, this document is essentially enshrining discrimination against physicians who have strong moral beliefs and object to a medical procedures that can have a value- based component. It creates a policy wherein these physicians are held to a different standard of care than the general body of physicians. They are being treated differently and there will be punitive consequences. That is the definition of discrimination.

Line 104 and 105 add the burden on ensuring the referral gets through. This is not true for non-objecting physicians. This is discrimination against the morally objecting physician. This is not based on the patient care. If that were the case this step would be true for all referrals.

There is an obvious misunderstanding of what is discrimination in the example of providing access to a physician who speaks a patient's language. Facilitating communication is a tenet of medical care. It holds no inherent bias about either party.

The section about providing access/referral to a patient's request for certain physicians based on social identity (which is by nature based on things considered discriminatory e.g. race/gender) is a minefield. It says you must judge the intent of the request to see if it is biased. How can we judge intent/motive without being discriminatory? We all have our inherent and cultural biases that may influence us without our own knowledge. This is untenable. Physicians have the potential to be wrong regardless of their choices because patients only see our actions and not our motives. This document's vagueness would not protect a physician, acting in good will, in a legal situation

This document needs to be totally revamped. Terms need to be more clearly defined. It needs to understand what discrimination is and is not within its own policy statements. There cannot be a double standard for care among physicians. It needs to remove discrimination against physicians with moral objections to certain procedures. It needs to clarify what are reasons to refuse/accept a referral for social identity reasons. The CPSO needs to fulfil its mandate of guiding the profession and protecting the public rather than confusing both parties as occurs in this document.
Organization
[November 28, 2022 3:29 PM]
Christian Medical and Dental Association of Canada
Response in PDF format.
Organization
[November 28, 2022 3:09 PM]
Canadian Physicians for Life
Response in PDF format.
Organization
[November 28, 2022 3:01 PM]
Ontario Human Rights Commission (OHRC)
Response in PDF format.
Physician (including retired)
[November 28, 2022 2:10 PM]
These documents contain proposals that are more draconian and coercive than previous versions. Document 1 (lines 35-36) would prevent a physician from even explaining his/her conscientious objection. Such a gag order ensures that the views supported by the College can be imposed and will be the only ones to get a hearing. This dogmatic proposal from the College is further strengthened (lines 39-40) by the suggestion that by refusing to refer, a physician who opposes being involved in ending the life of a patient is imposing his/her beliefs on the patient. Disagreeing with something is simply a disagreement, not an imposition on another. This is a nasty form of insinuation by the College and could possibly be interpreted as a hateful statement aimed at a dissenting physician. This a dangerous proposal for the physician and for the College. As a current patient I am very concerned by lines 49-61 in Document 1 which could certainly be interpreted as making it impossible for me to exercise my right to request that I am treated by a physician who shares my objection to being involved in ending the life of a patient. This is an unacceptable interference with my rights as a patient. In Document 2, previously severe proposals for effective referral have been made even more coercive by adding another obligation for a referring physician to ensure the patient has connected with the physician willing to be involved in ending the life of the patient. This is further disregard for a physician's conscientious objections and is forcing cooperation in a wrongful act. This same document also indicated that the College is ready to use its regulatory authority not only to undermine freedom of religion ( i.e. beliefs) and conscience for the individual physician but to impose the beliefs ('religio') of the College onto faith based hospitals and hospices. This is immoral and is tyranny. My final comment is on Document 3 in which it would appear that as a physician conscientious objector I will be obliged to provide a false and inaccurate death certificate, not one that clearly states how the patient died. This falsification is unacceptable for any death certificate. It is dangerous and wide open to abuse. The College desire to hide cause of death is very suspicious. To be compelled against one's conscience to falsify a death certificate is to be compelled to lie and to participate in a criminal act.
Physician (including retired)
[November 28, 2022 1:34 PM]
Well written. The CPSO position seems to be coming from a position of anti religion, anti conscience, and is clearly, though not stated, staunch personal atheism, which is in itself a belief system.

This CPSO position is far more political than medical and since a patient seeking MAiD can go directly to a MAiD help line, the heavy handed approach being taken by the College is unnecessary and condescending.

The other disturbing thing is the 'under the radar' approach that is being taken. This should be done out in the open with public consultation to a much greater degree than has been taken especially since this is something that has never in the history of modern civilization been done before with the exception of Germany in the 1930's.
Physician (including retired)
[November 28, 2022 1:33 PM]
Some content has been edited in accordance with our posting guidelines.
November 28, 2022
 
TO: Human Rights In the Provision of Health Services Working Group
 
Dear CPSO Committee Members,
 
[redacted]
 
1. An absence of a policy and barely a mention of ABLEISM within the entire body of the document. I believe this is a serious omission, especially with respect to the regulation of medical professionals.
 
What is Ableism? I have provided three definitions:
 
Ableism: Law Commission of Ontario:
Ableism] may be defined as a belief system, analogous to racism, sexism or ageism, that sees persons with disabilities as being less worthy of respect and consideration, less able to contribute and participate, or of less inherent value than others. Ableism may be conscious or unconscious and may be embedded in institutions, systems or the broader culture of a society. It can limit the opportunities of persons with disabilities and reduce their inclusion in the life of their communities.
 
Ontario Human Rights Commission:
OHRC- Ableism refers to attitudes in society that devalue and limit the potential of persons with disabilities
 
One I have used in undergraduate teaching:
 
- Ableism: Policies, attitudes, beliefs, and behaviours which intentionally or unintentionally favour able-bodied persons over persons with disabilities. It may reflect a value judgement such as perceived abilities or the quality of one's life.
 
In ways that are perhaps, more complex to read, you have attempted to address ableism within your policy. However, it should be defined clearly and noted in your Policy under line 26 Providing Health Services. How is the CPSO attempting to eliminate Ableism in the provision of healthcare services? How can physicians identify ableist attitudes?
 
For example, do they assign value to certain patient groups when enrolling new patients in a practice based on race, level of medical fragility, or type of underlying problems? Do they have an approach to the patient who is wheelchair dependent may be an obvious issue. (Does the receptionist come around to speak to the individual, is there an adjustable height examination bed, etc).
 
Regarding values or subconscious biases, simple exercises like an online 3-5 item MCQ test could be developed. Whether there is a policy of “first come, first serve” for family health teams, in registering new patients, the fact remains that many physicians continue to screen new patient records before agreeing to accept individual patients.
 
Sample exercise:
a. Would you rather have a 55-year-old drug addict in recovery as a patient, or a 30-year-old male mechanic with a new onset diagnosis of Chron’s disease?
b. Your practice is 98% full and you may enrol five patients this week. Do you prefer a 40-year-old Somali refugee in her 3rd month of residency or a 40-year-old Toronto-born mother of three, with a recent onset of Rheumatoid Arthritis awaiting specialty consultation?
c. Additional comparisons with persons who are well and young vs an 80-year-old with hypertension.
etc.
 
The “score" could be a qualitative review of what thoughts, beliefs, or experiences led to those choices. A picture and story of each fictional patient could be illustrated to provide greater context. The goal is to create empathy and perhaps dissuade physicians from making value judgements. Perhaps underscoring that patients should be registered in order of application, or possibly by a need in some cases (whatever the CPSO policy is presently, if one exists).
 
[redacted]
 
2. A. The definition of DISCRIMINATION is vague and missing key elements.
Line 13 Definitions:
 
The definition of discrimination is missing the groups and social grounds that the Ontario Human Rights Code recognizes as Code-protected. This is extremely important in a time when libertarian views are adopted by some. For example, we hear of “personal choices” with respect to mask wearing, and some individuals believe they are discriminated against if required to wear a mask in certain settings (as in medical practices). Not wearing a mask when it is required to do so by public health order or by an employer is not a human right. That is not accurate under the Code. These groups and social areas are not intuitive to many physicians. I have raised it with undergraduate medical students and most are not aware of the Code. Finally, working in the clinical setting as a physician with a neurological disability, I am most keenly aware that some physicians do not adhere to the Code even when considering fellow physicians like myself.
 
Therefore I would suggest a change on Line 14 (insert bolded language):
 
“ Discrimination: An act, communication, or decision that results in the unfair treatment of an individual or group “as defined by a Code-protected Ground or relevant Code-protected Social Area”, by either imposing a burden on them, or denying them a right, privilege, benefit, or opportunity enjoyed by others….
 
Include these categories should be mentioned directly under the definition in large print, not a footnote. A link to the OHRC website page would be appropriate.
 
Code-protected Grounds;
• age (older), sex, gender identity and gender expression , creed (religious Beliefs or practices), disability (includes drug use/addiction, HIV status), family and marital status, race and related grounds, receipt of public assistance, record of offences, sexual orientation
 
Code-protected Social Areas: contracts, employment, housing, membership in vocational associations and unions
 
B. Definition of Disability - This should be included on page one in large print under Discrimination, as it is another concept many physicians and students do not fully comprehend.
 
I note in footnote 6, the definition of disability under the Human Rights Code, R.S.O. 1990, c. H.19 Section 10 is not accurate.
 
If the Code is your reference, then the full definition should be provided:
 
Disability” means, (a) any degree of physical disability, infirmity, malformation or disfigurement that is caused by bodily injury, birth defect or illness and, without limiting the generality of the foregoing, includes diabetes mellitus, epilepsy, a brain injury, any degree of paralysis, amputation, lack of physical coordination, blindness or visual impediment, deafness or hearing impediment, muteness or speech impediment, or physical reliance on a guide dog or other animal or on a wheelchair or other remedial appliance or device,(b) a condition of mental impairment or a developmental disability, (c) a learning disability, or a dysfunction in one or more of the processes involved in understanding or using symbols or spoken language, (d) a mental disorder, or (e) an injury or disability for which benefits were claimed or received under the insurance plan established under the Workplace Safety and Insurance Act, 1997; (“handicap”)
 
3. Line 26 Providing Health Services:
Physicians should be aware of their obligations under the Accessibility for Ontarians with Disabilities Act unique for the clinical setting:
The College has an opportunity to raise these obligations in healthcare in this document. What is an accessible office? For example, having an adjustable height exam table that allows wheelchair-dependent patients to transfer for a proper assessment. (Literature exists that demonstrates wheelchair-dependent patients are examined less often).
 
4. Line 63 The Duty to Provide Services From Discrimination
Line 63 5. "Physicians must not discriminate, either directly or indirectly, based on a protected ground "or social area" under the Code…"
1a - Line 66 I would elaborate to include an example under 5a, to illustrate the problem with Ableist attitudes: “accepting or refusing individual patients, as with respect to the "level of acuity/frailty of the patient, age, type of condition, race, gender, etc." Most physicians do not believe patient frailty or acuity are Code-protect areas i.e. they believe accepting only healthier patient groups when their practices are near full enrolment is not in breach of the Code. It’s a question I have often posed to illustrate Ableism to undergraduate medical students and residents (ie. is it acceptable to accept healthier patients once you are fairly busy and nearing enrolment of your family practice? [redacted].
 
5. Add a section on Ableism and Medical Assistance in Dying: The importance of physicians removing themselves from the evaluation process should be stressed if they have identified potential biases that may be ableist in nature. For example, having a parent who died of ALS should cause family physician assessors to think very carefully before agreeing to assess a patient with the same diagnosis. When making such decisions, strong biases should be considered. A neurologist who sees all types of ALS patients, who had lost a parent to the same illness, would have a broader view of the same illness with the various disparate trajectories.
 
6. Line 89: Physicians must provide patients with “enough” information about all available or appropriate clinical options to meet their clinical needs…..
“Enough” is vague.
 
Simply a statement that physicians must adopt an informed decision approach by providing patients with all available treatment options for a particular diagnosis (some may not be considered “clinical”) including the arrangement of a referral to a professional/specialist who is more informed about particular treatment option(s) when warranted (ie beyond the full scope of the physicians’ training or understanding).
 
I hope my comments are helpful.
 
Kind regards, [redacted]
Physician (including retired)
[November 28, 2022 1:13 PM]
This is a short but well written position that I agree with.

There is no reason for CPSO coersion or what looks like coming very close to the line on bullying.
Other health care professional (including retired)
[November 28, 2022 12:09 PM]
Note: Some content has been edited in accordance with our posting guidelines.
Physicians need to be able to opt of if this wicked law.
Many are pro-life and cannot participate in murder whether it is the murder of anxious depressed teenagers who are persuaded to pursue MAiD or [abortion]. In this insane world of death Canada is embracing professionals/citizens need to have choice and freedom. Many will leave to other countries and Canada will have further issues in its lame medical system administered by the provinces.
Physician (including retired)
[November 28, 2022 10:45 AM]
Effective referral of the patient for a procedure that that the physician considers bad medicine makes the physician complicit in what she considers an poor medical practice. There are alternatives to effective referral that should be considered instead of making effective referral mandatory for the physician.
Physician (including retired)
[November 28, 2022 10:44 AM]
Making effective mandatory places the health care provider with ethical concerns in a tenuous situation. This predisposes the health care provider to moral distress, which occurs when one is unable to take an ethically appropriate or right course of action, including avoiding moral wrongdoing or harm, because of medico legal barriers. This moral distress can lead to moral injury in time, and adversely affect the provider’s mental health. Moral distress and injury are well documented in scientific literature and the ramifications of imposing effective referral in this regard should not be ignored.
Physician (including retired)
[November 28, 2022 10:23 AM]
Objection to Document 3: Line 96-100. This section seems to take out reference to MAiD in death certificates. Is this not falsification of documents? What should physicians put in place of MAiD? Something like… cardiopulmonary arrest? Note that I’m a physician who has experience in Eastern European terror regimes. The KGB has a long history of falsifying cause of death. I believe MAiD is murder. It goes everything against what I practice. If it is not, then why the need to falsify deqth certificates. Does the college give any grounds for conscientous objection against falsifying death certificates?
Physician (including retired)
[November 28, 2022 9:24 AM]
Awful policy. It is much too broad and draconian in stating that doctors are required to do wh. If a doctor does not think a patient should do something because the doctor believes it to be morally wrong, it should be within the doctor's right to say so. That is not imposition. That is part of what we hire doctors for--to ADVISE what they THINK IS BEST FOR A PATIENT.

Mandating "effective referrals" is an undue ideological imposition upon professionals attempting to suppress opposition to policies such as physician-administered death. If my doctor doesn't want to refer me for death, it's because he doesn't think dying is in my best interest. I can phone the death hotline myself. How does requiring the doctor to participate in the process benefit anyone other than the CPSO and government in muzzling those who disagree and imposing a façade of ideological unanimity?
Physician (including retired)
[November 28, 2022 9:19 AM]
A document that suggests we ought to incorporate "cultural humility, cultural safety, anti-racism, and anti-oppression" into our practice ought to reflect these principles onto itself.

The vast majority of my patients born outside of Canada - and whom I believe can rightfully suspected to be at risk of the racism and oppression this document pretends to concern itself with - would not agree with the ideology that transpires in this document. Most do not wish, whether speaking from the patient side or the practitioner side, for physicians to behave as automatons at the service of one of the most progressive healthcare agenda in any country, explicitly without any real room for freedom of conscience or religious freedom.

The fact that this document would not be acceptable by the vast majority of human societies in 2022 should give us pause. The CPSO, in fact, is imposing the view of the elite few on the many. Its attitude is more akin to ideological colonialism than "cultural humility".
Organization
[November 28, 2022 8:44 AM]
Ontario Trial Lawyers Association (OTLA)
Response in PDF format.
Member of the public
[November 28, 2022 7:01 AM]
The CPSO should NOT be forcing physicians to go against their conscience. Doctors should have the right to do what they believe is in the best interests of the patient. If they believe that offering MAID or referring for MAID as a solution to the patients problems is detrimental to the patients health they should NOT be forced to do so.
Organization
[November 28, 2022 6:16 AM]
Protection of Conscience Project
Response in PDF format.
Organization
[November 28, 2022 4:51 AM]
Jesuits of Canada
Dear College of Physicians and Surgeons of Ontario,
 
Having copied, but only partially read, 115 pages of your regulations in order to respond properly, I have come to a great respect and appreciation for your meticulous and profound care.
 
Over many years, with a lawyer's precision and detail, you have articulated this care for the training, practice and conduct of your profession.
 
Having trained and groomed them so well, please consider with the same care, what they are now saying to you.
 
They have the interests of you and your profession at heart because of your careful training.
Physician (including retired)
[November 28, 2022 3:16 AM]
There would be no need to define "effective referral" if there were no "objecting physicians". There would be no objecting physicians if they weren't being compelled to do something wrong.
It is pointless to say that physicians must not impose their beliefs on patients; they cannot. No one can be forced to believe anything.
Point 4 would enable the refusal of referral to a prolife doctor of someone who fears coercion to be euthanized. It would also enable the refusal of referral to an abortionist...but wait, point 9 says the opposite.
When you try to legitimize evil, it just gets more and more ludicrous.
Member of the public
[November 28, 2022 12:10 AM]
Physicians do not have problems with making referrals for ultrasounds, CT scans, cancer treatment, neurosurgery etc. Why? Because there is no question that these services enhance medical care. We should ask ourselves why, then, is there a resistance among some doctors to provide euthanasia. The answer seems obvious! No doctor should be required to provide a service that he/she does not believe will be in the best interest of the patient. I don’t want my doctor to be practising without a conscience. Do you?
Physician (including retired)
[November 27, 2022 11:59 PM]
Thank you for the opportunity to comment on the documents “Human Rights in the Provision of Health Services” and “Advice Document to the Profession re: Human Rights.”

There are a number of areas in these documents which I find concerning. These include the following:

The new requirement for physicians who object to participation in a given intervention on grounds of conscience or religion to not only make an “effective referral” but to take the further step of ensuring the patient has connected with the person or service to which the referral was made increases the degree to which physicians are expected to be complicit in an act that may contradict their most fundamental convictions about what it means to be human and, indeed, about what it means to do no harm. It further erodes conscientiously objecting physicians’ ability to be people of integrity in their practices and it is a further violation of their Charter rights to freedom of conscience and/or religion, over and above the violation already represented by the effective referral policy. As well, the draft policy does not appear to include any requirement for following up on a referral that is made for reasons other than conscientious objection. Perhaps I have misunderstood this requirement, but if it is indeed singling out conscientious objectors with a requirement that does not apply to other physicians with regards to the same clinical task, then that is discriminatory.

I can personally attest to the emotional, social and professional consequences of having one’s integrity perpetually threatened; the emotional and social distress associated with practicing under the effective referral policy as a physician who objects to euthanasia on conscience grounds led me to leave Palliative Care in 2019. Other jurisdictions have found ways of ensuring patient access to services to which some physicians might object that limit infringement upon physicians’ conscience rights to a much greater degree, but the CPSO insists on further encroachment on physicians’ basic rights to freedom of conscience and religion. I find this deeply troubling.

The requirement in section 8 of the draft policy for physicians to “provide patients with enough information about all available or appropriate clinical options” is particularly concerning when read in conjunction with the draft policy on “Medical Assistance in Dying” because it appears that the College is expecting physicians to initiate conversations with patients about euthanasia (especially given that the “Advice to the Profession” document on “MAiD” makes reference to the document “Bringing up Medical Assistance in Dying (MAiD) as a Clinical Care Option,” written by the Canadian Association of MAiD Assessors and Providers (CAMAP)). Listing euthanasia as a so-called “treatment option” in the same way that one might discuss palliative chemotherapy, rehabilitation options after a spinal cord injury, or electroconvulsive therapy for refractory depression, represents a huge paradigm shift away from euthanasia as an exceptional step taken in exceptional circumstances, to a run-of-the mill part of patient care. I do not think it is a stretch to assume that most people see the preservation of human life as the primary purpose of medicine. If we, as a profession, are expected to treat the killing of patients as an ordinary measure, and no longer an extraordinary one, that represents a significant departure from a worldview in which a doctor’s main job is to heal sick people. While I do not pretend to know the intentions of the College in writing these documents, upon reading them I cannot help but feel that they are insidiously pushing a re-framing of euthanasia onto the profession. The potential impact of such a re-framing deserves an open and thorough exploration into the potential effects on patients, physicians, and the health care system. I do not see evidence of such an exploration in any of these documents.

Section 2a of the Draft Policy forbids physicians from expressing “personal moral judgements” about “the health services patients are considering.” This makes it impossible for a physician who objects to a given intervention on grounds of conscience to explain his or her objection. Any kind of human exchange regarding the service being requested becomes very difficult; all the physician can say is “I don’t do that.” What is he or she supposed to say if the patient asks why? Furthermore, the CMA Code of Ethics actually requires physicians to “Inform the patient when your moral commitments may influence your recommendation concerning provision of, or practice of any medical procedure or intervention as it pertains to the patient’s needs or requests” (Section C, “Professional Responsibilities,” number 4). The Draft Policy completely contradicts this advice.

Also, section 2c, which forbids physicians from “promot[ing] their own spiritual, secular, or religious beliefs when interacting with patients or impos[ing] these beliefs on patients” could be broadly interpreted to include the refusal to provide certain services on grounds of conscience or religion. While I do agree that physicians should by no means try to convince patients of a particular moral, religious or philosophical belief or belief system, this is a very different thing from a physician simply acting in accordance with his or her own moral beliefs with respect to his or her practice of medicine. This clause requires clarification as to what exactly is meant by “promote” and “impose.”

“Advice Document to the Profession re: Human Rights” specifies that physicians working in faith-based institutions must provide “access to information and care, including an effective referral, for the services, treatments, and 338 procedures that are not provided in the faith-based hospital or hospice” (lines 336-338). This statement lacks clarity about exactly what is expected. Is there an expectation that physicians working in faith-based institutions would actually provide “care” that contradicts the policies of those institutions? For example, is the CPSO suggesting that a physician working in a Catholic hospital should actually provide euthanasia, even if the hospital has a policy against euthanasia being done on its premises? If not, then this needs to be clarified. If so, then effectively the College is encouraging physicians to undermine the policies of faith-based institutions. I believe the latter would represent a serious over-reach of the College’s power and I sincerely hope that this is not what is being suggested.

I thank you again for the opportunity to comment on these documents and I implore you to please carefully consider my concerns.
Physician (including retired)
[November 27, 2022 11:52 PM]
I have the following issues with the Medical Assistance in Dying and the Human Rights in the Provision of Health Services policies:
1) Physicians killing their patients
2) Disregard for conscience rights and mandating effective referrals
3) Insistence that physicians lie on a medical document about the cause of death

1) Physicians killing their patients
MAID is an euphemism for killing patients.

Details are changed so please don’t redact this. I know an adolescent boy in Canada who had sudden onset paralysis from the neck down. To the horror of the patient and his parents, one of the physicians on their medical team proposed assisted suicide as a “treatment option” because he wasn’t improving. They understandably lost faith in the medical profession and felt like their team had given up on their child.

It’s hubris on the part of our society, the physicians offering assisted suicide, and the College to think that they know whose life is no longer worth living. To insist on offering death under the façade of autonomy shows a complete disregard for the aforementioned boy and countless others with disabilities and mental illness who will be harmed by policies such as these. Patients who are suffering need hope and our help, not an offer of death.

2) Disregard for conscience rights and mandating effective referrals
Regardless of one’s views on assisted suicide, why in the world would you want to raise up a generation of physician who are so lacking in moral reasoning and conviction that they are willing to refer a patient for something they believe to be wrong and harmful to the patient?

There is no evidence that mandating an effective referral is necessary for ensuring patient access to assisted suicide. I challenge the College to publish such evidence if they have it. Many provinces have found ways to ensure patient access (e.g. hotlines for outpatients, direct transfer of care for inpatients) without infringing on the conscience rights of physicians.

The attempt to pit a physician’s conscience or beliefs and values against professional obligations and patient care is ludicrous. Many of my colleagues with differing worldviews have values and beliefs which motivate them to dedicate themselves selflessly to the care of their patients. Allowing it to guide our care for patients when convenient for the College then asking us to completely disregard it the next is preposterous.

3) Insistence that physicians lie on a medical document about the cause of death
This should be self evident… It’s disgraceful, dishonourable and unprofessional. The very conduct that the College is supposed to prevent and discipline its members for. I understand the concern for patient privacy but it doesn’t justify forcing physicians to lie.

The College disregards the ethical and moral norms that have guided our profession for millennia (e.g., to first do no harm and to respect the conscience of our colleagues) to the detriment of our profession and the wellbeing of our patients.
Physician (including retired)
[November 27, 2022 11:50 PM]
I am concerned about the current draft of this CPSO policy. I agree that all Canadians need to be included in healthcare that is free from discrimination. Healthcare has become increasingly difficult given the introduction of controversial issues, which are founded primarily within philosophical or worldview frames of reference, and are by no means founded on empirically based best practices. I find it noteworthy that the CPSO is updating this policy draft at the same time that it is updating the MAiD draft. Excuse me for possibly reading between the lines, but I am concerned that the new wording of this document is perhaps an effort from the CPSO to get physicians on board with MAiD legislation, which has become quite dangerous for many of our patients. Having reviewed the document, I must say that it seems more to curtail the human rights of physicians, than perhaps it intends. For example, it is a violation of a physicians human rights to be prevented from withholding an inappropriate service to a patient who otherwise is demanding such. The physician can decide, and does all the time in practice, which treatments are appropriate and which are not. Simply because the patient demands a specific treatment does not compel the physician to provide such, nor a referral to someone who will accomodate an inappropriate or unsafe request. I am concerned that this update to the CPSO policy will make it more difficult for physicians to act in good faith in the care of patients, and thereby jeopardize another safeguard within our healthcare system to guard against potential harms. Given the potential harm that the current MAiD legislation and regime poses to Canadians, it seems to me that this is perhaps an unwise time for the CPSO to proceed with the listed changes. Canadians need Canadian physicians to have the ability to blow whistles and protect patients, especially given the rapid expansion of MAiD to problems that it was never intended to "treat".
Physician (including retired)
[November 27, 2022 11:23 PM]
1. It is unethical to force physicians to effectively refer patients for procedures that they do not consider to be in their patients' best interests. A referral is not merely an administrative act but is an explicit recommendation of a specific course of action.

2. Declining to provide a certain procedure could be (mis-)interpreted as expressing/imposing spiritual/moral beliefs.

3. Re: Limiting Health Services for Clinical Competence/Scope of Practice Reasons. Paragraph 6.a implies a requirement that physicians provide and/or become competent in contested procedures due to lack of services.
Physician (including retired)
[November 27, 2022 11:08 PM]
"Human Rights in the Provision of Health Services" means respecting a physician's right to be a Conscientious Objector. There is no reason that a physician must make an "effective referral" for MAID. Several provinces already have a centralized registry so that patients may self refer.

A Faith Based Hospital or Hospice is appreciated by many patients and families who want a focus on "living well until they die" as envisioned by Dame Cicely Saunders. Again, if self referral is an option, Faith Based Hospitals or Hospices do not need to participate in procedures that violate their ethical boundaries.
Physician (including retired)
[November 27, 2022 9:57 PM]
Please clarify:

- Which morality of medical care we are allowed to discuss with patients and which we are not. For example, can we still discuss the morality of a patient:
...lying about their HIV/syphilis/Hepatitis status to unprotected sexual partners?
...lying to their employer about their medical illness?
...asking us to lie for them to their employer or the Ministry of Transportation?
...driving drunk or under the influence of substances?
...recurrently becoming violent towards others because they are non-compliant with essential medications or therapy?
...requesting prescriptions for medications under their partner's name due to insurance coverage?

- How a doctor can LEGALLY PROVE if a complaint is lodged against them that they are sufficiently anti-racist to adequately satisfy these regulations and avoid censure.
- Whether doctors can provide preferential treatment for or against individual patients based on their skin colour to satisfy anti-racism.
- Whether patients can complain to regulators that they have not been given preferential treatment on the basis of their skin colour or other identity to satisfy anti-discrimination.
- Whether a doctor is being discriminated against when a patient refuses to accept medical care from the patient on the basis of the doctor's skin colour or other identity.
- Whether a doctor's skin colour or gender/sexual identity will be relevant in any potential complaints about their behaviour to the CPSO.
- What the exact hierarchies of racial/identity/sexual/gender discrimination we should use are for judging who to provide preferential treatment for or against to satisfy regulations.

These rules are the judgment by which we remain licensed medically. There need to be object and clear standards to judge compliance or guilt of any doctor in any circumstance.

Blanket rules that make no sense in an actual medical practice (like banning discussion of medical ethics) have no position in a document like this. All this does is allow frivolous complaints from patients and prevent doctors from mounting any adequate defence.

Ambiguous and subjective rules that provide no obvious manner for assessing compliance or failure towards compliance cannot serve any valid purpose and are only a danger in a regulatory function, which is the CPSO's mandate.

Furthermore rules that enshrine avenues for potential discrimination rather than reject discrimination are counterproductive to a goal of seeking less discrimination in the world. These rules are made worse also by the same fact that they similarly cannot be proven or disproven in any measurable way, and thus a doctor's innocence cannot be proven in the face of a complaint.
Physician (including retired)
[November 27, 2022 9:50 PM]
I wish to commend a number of earlier posts from concerned individuals and organizations including those representing individuals with disabilities and Indigenous peoples. These have stated a number of concerns I share much more eloquently and poignantly than I am capable of expressing from my privileged and limited vantage point.

I would, however, respectfully share some additional reflections that came to mind as I reviewed the draft policy and companion document.

This document is internally inconsistent. Physicians are not to promote particular beliefs, but it seems that anti-discrimination and related concepts are an exception and that physicians actually must take reasonable actions to stop discrimination. Everyone has beliefs and biases that they may or may not explicitly recognize and acknowledge. I think that it is unreasonable to suppose that they do not and should not promote them where appropriate. For example, a number of my patients are anti-vaccine and I promote my belief based on scientific evidence that vaccines are beneficial in a manner that is patient centered, respectful and sensitive, but it would seem that such action would contravene this policy. This document is opposed to the practice of ethically sound, evidence-based medicine.

Expectations in this document around referral and its confirmation are particularly unrealistic in the current healthcare and economic environment of Ontario where wait times for evidence-based therapies are often measured in years. Many of my most vulnerable patients are unable to access evidence-based assessment and treatments that could alleviate their suffering and I think that sections of this policy will worsen burnout and workforce limitations that exacerbate rather than alleviate long standing inequities. In particular, there are patients in my practice who have expressed a desire to receive MAID because the wait for interventions that might enable them to live with the quality and dignity they desire are simply unavailable within a timeframe acceptable to them in the public healthcare system. As one of these marginalized patients with mental and physical ailments desiring MAID recently stated "I can't afford to live any more." I find this morally distressing and am trying to support these suffering patients in a manner that may help them to find purpose and hope to continue living because I believe that this is possible even though they may not at this time.

Thank you CPSO for taking these thoughts and stories into consideration as you review your policy and consider revisions that will promote the health and wellbeing of everyone in Ontario.
Physician (including retired)
[November 27, 2022 9:19 PM]
To the Ontario Government and CPSO policy department:

My husband and I are two concerned family physicians practicing in rural Ontario. We share many concerns of the Bill C-7 and the detriment it holds to the lives of Canadians. From what I understand, Bill C-7 will expand access to medical assistance in dying (MAiD) to those with chronic illness, disability, and mental illness.

Our concerns lie in the unclear and unfair wording of the bill which states that physicians have a right to conscience and participation in MAiD should be voluntary; the physician MUST, however, provide an effective referral and ensure that this referral is effective. This necessarily negates the individuals’ right to conscientious objection, as they must follow up on an action they have not agreed to (a stipulation that a non-conscientious objector must not follow through with).

The Bill also proposes that physicians must offer the option of MAiD as a medical treatment for illness. If the physician does not believe this is a medically appropriate option, they must not say that they object for personal reasons, but should feel empowered to express their professional medical opinion, which offers better alternatives. Furthermore, suggesting this to a vulnerable patient who may be in crisis and sees death as a professional recommendation at the moment, but has the ability to recover with appropriate and comprehensive medication and psychological support systems which the medical system should be able to offer, but unfortunately, is not readily available to many Canadians (this is my first-hand experience with mental health referrals).

We request your policies be reconciled to respect conscience and patient safety in all patient settings. We ask the government to fulfill its duty to protect vulnerable persons and its health care workers. We can honestly say that as two physicians, we feel trapped and threatened in our current medical system with regards to MAiD requests. We feel that we are not able to express professional medical judgment for fear of reprimand.

I certainly hope that the CPSO takes into consideration the serious implications of Bill C-7 and continues to advocate for physicians like me.
Physician (including retired)
[November 27, 2022 8:59 PM]
I am concerned that the CPSO is creating an environment where doctors who have taken the Hippocratic Oath are no longer welcome to practice in Ontario. It is possible to have conversations with patients and express a different opinion without doing it in a condescending or judging manner. It seems as if the CPSO thinks that if a doctor expresses their ethical viewpoint on a matter which is different from the patient, then this is interpreted as forcing the patient to think along the doctor's viewpoint. I wonder at times how long I will be able to continue practice medicine in this province. I agree with the Canadian Society of Palliative Care Physicians that patients should be the ones to initiate discussions about MAiD. I agree that with the power imbalance between doctors and patients, that patients might think the doctor is giving up on them. I also agree that MAiD is the responsibility of the entire health care system and not just one individual doctor. In Ontario, when it comes to abortion, women are able to obtain an abortion without a referral. This is the most efficient way for them to obtain an abortion and allows for doctors who are conscientious objectors to abortion to be able to continue to practice medicine without creating conflict over a referral. In some other provinces, systems have been set up where people can access MAiD by self referral as well. This allows for the patient to access MAiD if this is their desire and it allows the doctor to continue practice without moral distress over having been involved in a process which they consider to be harmful to the patient. It seems like CPSO is using its power to force all physicians to practice according their ideology rather than allowing physicians to be able to practice according to their own ethical standpoints and strive to work cooperatively with their patients who may have different viewpoints.
Physician (including retired)
[November 27, 2022 8:57 PM]
Response in PDF format.
Physician (including retired)
[November 27, 2022 8:23 PM]
Human Rights Document
Lines 99-108:
This is extremely concerning and a step beyond what is required with any other referral I do as a family physician. Why do physicians who object based on moral/religious grounds have to go above and beyond what they would normally do for a referral to ensure a patient was connected? These lines should be removed.

Line 89-91
Physicians should NOT under any circumstances be presenting MAiD as a standard option for patients when exploring options for care. What is our profession coming to? My first obligation is to do no harm. It is unacceptable to be asking a vulnerable patient about this exceptional option when the patient does not bring it up.

Lines 75-58
Are physicians expected to develop competence in areas they are incompetent in the name of "access?"

Advice to the profession document:
Line 333-338
Why do physicians working in faith-based settings have to provide care that is not offered in that setting that they may be morally opposed to? Or is just an effective referral required? This is unclear. These lines should be removed.

This policy and document needs to be revised and needs to stop weaponizing physicians of particular faith backgrounds. Religious discrimination is rampant in these documents and many of our patients are from religious backgrounds. I remind policy drafters that religious freedom is protected in Canada's Charter and vague wording is not helpful for physicians in practice.
Furthermore, why is gender and ethnicity being asked for physicians who are posting on this forum? I would hope comments are not being selected or discriminated against based on these aspects of identity. Thank you for opportunity to participate in the consultation.
Organization
[November 27, 2022 7:17 PM]
Canadian Association For Suicide Prevention
Response in PDF format.
Physician (including retired)
[November 27, 2022 6:08 PM]
Running roughshod over the conscience rights of physicians is shocking in the least. The CPSO is stepping way beyond their mandate. The constitution guarantees these rights over the OPINIONS of the College. None of this is medically necessary. Falsifying MAid records is truly UNBELIEVABLE. When is lying an acceptable approach to anything. The CPSO is clearly tumbling out of control...this madness needs to stop. Sober second thought needs to be brought to bear.
Physician (including retired)
[November 27, 2022 5:56 PM]
I am concerned that while the CPSO is trying to promote cultural humility, there seems to be a lack of cultural humility in certain parts of the documents. For example, requiring physicians (including those in faith-based hospitals/hospices) to provide effective referrals for procedures that are inconsistent with their own values or the values of their institution, represent one cultural view. In particular, they reflect bioethical principles arising from the dominant secular Western European/North American culture. However, they may not be representative of other cultures and other ways of knowing, especially from different parts of the world, which may see these issues through very different lens. Cultural humility should mean the CPSO recognizes that physicians will have a wide range of different cultures, backgrounds and knowledge, and thus widely different views on effective referral for controversial procedures, and that this diversity should be valued rather than reduced.
Physician (including retired)
[November 27, 2022 5:39 PM]
The CPSO has no credible evidence that trampling on the conscience rights of physicians is necessary to provide adequate "care" for those who want to kill or mutilate themselves. It won't be long before physicians are required to comply with patients who want to cut off their limbs because they don't "identify" with them. It's coming. If it is necessary to provide an option for death, why is it wrong to provide or discuss an option for life? Or living with a disability? Why is the CPSO so quick to punish doctors for not killing a few patients fast enough, yet have little or no empathy for the millions in Ontario who are suffering, waiting for joint replacements or back surgery? The CPSO is clearly pro death and mutilation.
Member of the public
[November 27, 2022 5:19 PM]
I am writing in complete opposition to any and all laws, bills, and legislation regarding MAiD, MAD, and/or legislation of laws or bills that force Doctors & Nurses to give treatment that is against their conscience and/or religious beliefs, as well as against the Hippocratic Oath.
I don't have time to list all the reasons why I strongly oppose the newfangled ideas that medically murdering people should be an acceptable medical procedure.
Have we become so callous, hard-hearted, blinded and delusional to forget that mankind is actually responsible to care, support, comfort and assist his fellow man in every way possible?!
This killing way of thought quite unbelievable: that governments and medical "professionals" could stoop so low as to imagine this is acceptable or preferred, and all of it is over money, of all things. As if killing ailing human beings is to be preferred to giving them treatment! What monsters those have become who think like this! You can be sure it will backfire on you; that when your own day of need comes, your only "help" will be a killing injection.
Won't that be a cheery day? And you will have earned it!
This is Nazi Germany all over again.
Physician (including retired)
[November 27, 2022 4:43 PM]
Lines 35-40: express personal moral judgements... impose their spiritual... beliefs - clause is too broad as it can be interpreted to include any communication in a clear and straight forward manner any conscientious objection, any of which have spiritual/moral beliefs and judgements behind the objection.
Physician (including retired)
[November 27, 2022 4:18 PM]
The Canadian Charter of Rights and Freedoms applies to the acts and conduct of government, which includes the CPSO. Section 2(a) of the Charter guarantees freedom of conscience. In trying to ensure the public has access to MAID, the CPSO demands physicians who are conscientious objectors to become complicit by requiring them to provide an effective referral.
The CPSO must balance competing the rights/freedoms of patients and physicians properly; there are methods of ensuring patient access to MAID without infringing on the rights of physicians. The burden of providing access to this service lies with the government, not individual physicians. The availability of a centralized self-referring service for MAID would satisfy both the competing rights without infringing on either party's rights. I request that the CPSO consider its obligations under the Canadian Charter of Rights and Freedoms carefully.
Physician (including retired)
[November 27, 2022 3:35 PM]
I would advise the CPSO to observe the charter of rights for all Canadians, including those who do not wish to be involved in MAiD The new drafts appear to have a forceful stance for both patients as well as physicians. Please include the rights of those who do not wish to be involved at all in this controversial and previously illegal practice. There are many physicians- in fact most physicians - do believe the purposeful act of ending a life is immoral, although legal. We must ensure the rights of this view of the majority are included in any guidelines. Please do not add to the moral distress already rampant in our profession.
Physician (including retired)
[November 27, 2022 3:22 PM]
It is hubris for the CPSO to write as if profound differences of thought and belief can be "referred" away without serious moral injury to those who are bullied into compliance and cupability with acts that they consider to be deeply wrong. You have accepted the idea from CAMAP that medically administered death is just one more treatment option. Not so for those who are morally opposed to complicity with intention killing, and to be unable to see that is willful blindness.
Physician (including retired)
[November 27, 2022 3:21 PM]
It is unreasonable to require physicians to make "an effective referral" when self referral is clearly working successfully in Alberta. (and partly shows the person requesting is competent.)

Physicians working in faith-based hospitals do inform a patient of options but should not have to make an "effective referral." That is the purvey of a competent patient (as above.)

The corollary: The College should mandate appropriate referral "FOR CARE" when the patient request it and not allow doctors to do the equivalent of a 'slow code' and deprive a patient of care just because they believe it is pointless.

MAID is not a "treatment" option: MAiD is as an exceptional service.

A refusal to kill a patient through MAiD is not "imposing spiritual, secular or religious beliefs.”
Physician (including retired)
[November 27, 2022 3:18 PM]
The current draft seems to completely ignore the concerns and perspectives of our palliative care colleagues. Aren't we having enough trouble providing palliative care, without pushing away those PC doctors who firmly believe that medically administered death has no place in PC?
Physician (including retired)
[November 27, 2022 2:59 PM]
Exactly.
Physician (including retired)
[November 27, 2022 2:58 PM]
I am simply recording my agreement with this submission.
Physician (including retired)
[November 27, 2022 2:41 PM]
This is a draconian document both on practical and conscience dimensions. Has anyone noticed that primary care is in crisis, and you want to load MORE administrative burden and moral distress onto overworked, frazzled family physicians?

It's not enough to compel effective referral for things individual physicians may feel are wrong--you must also follow up and ensure patients connect with those services? This dehumanizes the family physician even further into a widget producer. In my 16 years of experience, patients often enquire but do not follow through with what they have asked about (MAID, abortion, etc)--to follow up further is just to push people onto an assembly line.

Note, effective referral IS complicity in the objectionable act. Anyone who believes differently is encouraged to look into the Maher Arar case.

Now you are also suggesting that we connect the patient with the type of physician they want? E.g. a female, a French speaker, whatever--there are thousands of unattached patients in our community who are unable to access ANY primary care; now you want us to spend our precious time navigating these patients to their exact preferences? This further crowds out unattached patients and actually CREATES more inequity than it proposes to alleviate.

This is an ill-advised document that will accelerate physician moral distress, moral injury, burnout, and suicide.
Physician (including retired)
[November 27, 2022 2:19 PM]
My thanks to our American colleagues who have so carefully and clearly articulated a much more balanced approach to ethically contentious issues.
Physician (including retired)
[November 27, 2022 2:17 PM]
I absolutely agree.
Physician (including retired)
[November 27, 2022 2:14 PM]
I wholeheartedly concur.
Physician (including retired)
[November 27, 2022 2:12 PM]
"Regardless of one's opinion of MAiD, the right to self-determination and to act on one's conscience is recognized as a fundamental freedom in all peoples." I support what has been written here. I assert that it should apply to all physicians, Indigenous and otherwise.
Physician (including retired)
[November 27, 2022 2:10 PM]
I just want to add my support to what has been said here.
Physician (including retired)
[November 27, 2022 1:31 PM]
To the College of Physicians and Surgeons of Ontario Policy Department;
 
I write to you with concerns regarding the CPSO’s draft policies on “MAiD” and “Human Rights in the Provision of Health Services”.
 
The two domains I wish to address are conscience adherence and clinical wisdom in the assessment of patient vulnerability.
 
With these draft policies, the CPSO appears to diminish these two important tenets of the practice of Medicine.
 
First, the development and exercise of conscience is central to meeting a physician’s fiduciary obligations to all patients as a physician appropriately guides and treats their patients. Emasculating conscience risks great harm to the array of challenging situations in which a physician and patient determine the best course of action together. We are all aware of numerous troubling historical examples in which authorities and laws were simply wrong, sometimes abhorrently so. Ought not conscience remain as a core character feature of physicians? In the case of MAiD, systems exist in other provinces such that patients who seek this legal procedure can readily be connected to an efficient, expert and broadly available service without requiring the participation of every physician. Those successful mechanisms assure availability for patients while protecting conscience adherence on the part of physicians, appropriately balancing the imperatives demanded in the Supreme Court’s decision in Carter.
 
Second, patients may well be significantly harmed by a proscription that requires physicians to inform all patients who may be eligible, about the option of assisted death. At a time of diagnosis of a potentially life-limiting illness or while being in a pathway of treatment/management of a chronic condition, do we adequately understand the impact on a person of being informed that an option is to be made dead? Is the patient particularly vulnerable in those interactions and should physicians not be encouraged to consider ideal timing of such conversations? The CPSO ought not debase the notion of clinical wisdom, carefully exercised while assessing the context, values, beliefs and history of each particular patient.
 
Please be mindful of these concerns as you deliberate on these two draft policies.
Physician (including retired)
[November 27, 2022 12:31 PM]
During my first read, I was surprised by 1. The definition of discrimination was left vague and open to interpretation - unlike any I have ever seen (after following this literature for 25 years, since the onset of my own disability). It did not include the Grounds and Social Areas in the Ontario Human Rights Code. Discrimination is not a state of mind. In its present form, people who don't like masks could claim discrimination, for example. 2. There is no policy or definition of Ableism. This is a gross omission of a human rights policy governing health professionals. I see Council for Canadians with Disabilities also raised this concern. Ableism] may be defined as a belief system, analogous to racism, sexism or ageism, that sees persons with disabilities as being less worthy of respect and consideration, less able to contribute and participate, or of less inherent value than others. Law Commission definition: Ableism may be conscious or unconscious, and may be embedded in institutions, systems or the broader culture of a society. It can limit the opportunities of persons with disabilities and reduce their inclusion in the life of their communities 3. Omitting the risks of bias associated with MAiD was also an oversight. This should be presented clearly. 4. The language is cumbersome in places, with many "musts" without additional context, which may be necessary for some physicians without knowledge of the Code or experience in accommodation.
Physician (including retired)
[November 25, 2022 11:04 PM]
Note: Some content has been edited in accordance with our posting guidelines.
To Whom it May Concern:
 
I am an academic palliative care physician practicing at [redacted] Hospital. I urge you to reconsider several aspects of your revised policies as they pertain to MAID and their impact on the palliative care and human rights of the patients I serve.
 
Human Rights and the Obligation to introduce MAID as a Choice: By shifting professional obligations concerning MAID to the revised Human Rights policy, CPSO proposes to introduce an obligation to “bring up” MAID as an option in the many clinical situations in which MAID is now legal. Initiating a discussion of MAID with a patient will cause harm in a significant proportion of the patients for whom I care. This can be so easily misconstrued as a physician recommendation and thus represent a form of coercion. Patients struggling with severe illness or disability already exist in an emotionally and ethically charged situation. The professional needs to approach such patients with great caution particularly knowing the well-documented power imbalance in the patient-physician relationship. Vulnerable populations (e.g., people who are disabled, frail & elderly, racialized, mentally ill) often have valid reasons to mistrust the health care system and initiation of a MAID discussion without a prompt from the patient will destroy the potential to rebuild that trust. The empathetic physician should be asking open-ended questions but never initiating the discussion of MAID which often will be interpreted as proposing a course of action. Additionally, a new obligation for the physician to “take positive action to ensure the patient is connected” could be interpreted as an obligation to bring up the topic a second time to an ambivalent patient who has decided against pursuing the referral and that patient could interpret the physician action as further pressure in a power-over dynamic. Care planning should continue to be a matter of professional judgement and not rigid policy directive.
 
MAID and its Impact on Human Rights: I would encourage the College to reconsider the wider implications of MAID by taking a more neutral or even at times a more skeptical stance on the impact of MAID on the human rights of Ontarians. Your proposed policy revisions presumes that MAID is an obvious and unqualified advance in those rights by enhancing the autonomy of patients. Tightening of ‘effective referral’ criteria implies that some physicians who choose to limit their participation in the MAID process are blocking access and imposing their personal beliefs on their patients even though no evidence is presented to substantiate this fear. By positioning these rules within the Human Rights policy, the College implies that any skepticism about MAID will be viewed as a marker for opposition to human rights in general. In some provinces with higher rates of MAID there are no comparable restrictive policies on referral. If CPSO pushed the government of Ontario to fund a robust MAID coordination service that accepted referrals from both professionals and patients (as in Alberta), access issues, real or perceived, could be resolved easily and without threatening physicians with more rigid referral criteria.
 
The first years following legalization saw MAID embraced, in large part, by the white, educated, wealthy, privileged boomers who hold autonomy as their highest value. But the situation is fast changing. Ontario is a society with major structural inequalities that impact the health care of vulnerable sub-populations– people who are racialized, indigenous, disabled, homeless, experiencing chronic mental illness or addictions. With rapid MAID eligibility expansion, we can expect to see increasing numbers of patients from vulnerable sectors choosing MAID because they perceive that they have no other good choice. The lack of appropriate resources in health care, housing, social services, palliative care, and mental health care reinforces their belief that here is no other option. This poses a far greater threat to Human Rights than the imagined blocking of access by relatively few non-participating physicians. I would urge the College to refocus their policies on MAID and Human Rights to emphasize the strengthening of safeguards in the health care system including more robust palliative care so that no one in Ontario chooses MAID because of lack of resources or because of underlying structural inequalities.
 
Thank you for asking us to participate in your deliberations.
Organization
[November 25, 2022 6:17 PM]
Disability Filibuster
Response in PDF format.
Physician (including retired)
[November 25, 2022 2:38 PM]
Hello,

I would like to provide input to the draft CPSO policies regarding MAiD and Human Rights in the Provision of Health Services.

My understanding of these policies as written is that they provide for the following:

1. A duty to inform patients of all treatment options for which they are potentially eligible, including MAiD. CPSO references the Canadian Association of Maid Assessors and Providers (CAMAP) Bringing up MAiD document which states raising MAiD to all potentially eligible patients should be standardized practice.

2. Physician objections to MAiD have been reframed as personal/individual beliefs instead of evidenced-based professional objections shared by many expert groups.

3. A new positive obligation is to be placed on conscientious objectors. They must ensure an effective referral was successful by confirming with the patient that they were connected with a MAiD provider/assessor or coordinating service. Those who make referrals but do not object to MAiD are not required to make such a confirmation.

I request that your policies be reconciled to respect physician conscience on these matters as well as patient safety in all patient settings. Physician objections to MAiD are not simply personal beliefs but have evidence-informed backing. A physician who objects to MAiD should not have a duty to inform patients of treatment options which , in their clinical determination, is not in the patient’s best interest. And certainly no positive obligation can be placed on these physicians.
Organization
[November 25, 2022 12:10 PM]
Canadian Society of Palliative Care Physicians
Response in PDF format.
Organization
[November 25, 2022 8:29 AM]
Information and Privacy Commissioner of Ontario (IPC)
Response in PDF format.
Organization
[November 21, 2022 4:14 PM]
Council of Canadians with Disabilities
Response in PDF format.
Organization
[November 21, 2022 12:01 PM]
Toujours Vivant-Not Dead Yet
Response in PDF format.
Member of the public
[November 21, 2022 11:16 AM]
Dear Sir/Madame

I'm contacting you in regards to your human rights segment. What exactly are you saying? My body is my choice like a womens body is her choice when it comes to such things as abortions.
I am the one who decides what goes into my body as I'm the one who has to take care of myself.
I will under no circumstances be told what I must put into my body when it comes to a flu shot or any type of vaccine.

Can you please explain to me what changes your trying to implement?

Thank you
Physician (including retired)
[November 20, 2022 11:45 PM]
The human rights policy has quite some concerning statements.
Line 54 - (Point #4) As a person of color I find this quite shocking. There are SO MANY instances where women and / or people of color face discrimination daily because patients conveniently don’t want to see us and ask for “male” doctors or “white doctors”. Patients are not going to say they are racists (like 59)… but can always come up with subtle “excuses”. This is going against EDI that CPSO is committed to promote. I hope you consider rephrasing this to say something along the lines of in Canada we can’t always guarantee a physician of a certain social identity (maybe exception I can think of is if someone doesn’t want to see a physician for religious reasons like Muslim women don’t want to see male doctors, even that is a stretch) … and it is NOT my job (in non emergent case) to accommodate someone. Patients in non-emergent cases can go looking for that themselves. Otherwise, how are we as physicians also to know the “social identity” of all our colleagues? Is that something we are going to start publicly advertising?

Line 84 (point 7) and Line 99 - absolute disgrace. Even though I am pro-choice pro-MAID etc, I still empathize with many colleagues who get anxiety attacks over the fear of having to refer patients to such services (such as MAID) due to conscious conflicts. Just like there is public lists of where patients can access abortion, why can’t such lists be made for MAID and other such services that have conscious consequences? Some MDs feel that even providing that service is contradictory to the oath they took. I know CPSO is to protect public but if physician conscious and wellbeing is not protected it will contribute to burnout and exit from profession.

Line 128 (Point 13). I’m surprised that CPSO wants physicians to step in. We can encourage the staff/patients to seek help / call 911 but saying that MDs “must” … we are not the morality police. How much outside our scope are we expected to practice? Maybe phrase to say “encourage” instead of “must”?

I see discrimination of all kinds every single day I work. If I tried to step in every time I would have zero time to actually do patient care. We can be encouraged but… what is up with the “must” language everywhere? Can we be doctors and actually focus on good clinical care?
Physician (including retired)
[November 20, 2022 4:30 PM]
Given the concern about poor physician staff treatment by hospitals, I would like to see guidelines specifically identify the treatment of Medical Staff by more senior physicians that have a dedicated hospital position, often a true employee of the hospital, such as Chief of Staff and Department Heads, Adminstrators, etc.
Physician (including retired)
[November 20, 2022 12:47 PM]
To Whom It May Concern:
 
I write to inform you that the Council on Ethical and Judicial Affairs of the American Medical Association, of which I am a member, supports referral for information but opposes so-called "effective referral" for a procedure that is legal and requested by a patient but violates the deeply held moral convictions of the physician. Opinion 1.1.7 and the CEJA report of 2014 on this matter are attached.
 
I hope that the positions and arguments supporting them that are contained in these documents will seriously inform your deliberations.
Physician (including retired)
[November 20, 2022 12:25 PM]
The policy does not clarify what a physician's obligations are when faced with sexist / racist / ageist patient with an emergency condition. Are we obliged to treat? find an alternative provider? punt back to the referring physician, if applicable?
Member of the public
[November 20, 2022 12:02 PM]
I agree it is a Policy for an Authoritarian Gov't to overule a Doctor's Oath This policy empasizes too much on race & gender rather than the health of any & all patients or privacy between Doctor patient
Physician (including retired)
[November 19, 2022 6:43 PM]
True
Organization
[November 19, 2022 4:25 PM]
Canadian on Paper Society for Immigrant Physicians, Foundation of International Medical Graduates, Alliance for Doctors Denied by Degree, and Society for Canadians Studying Medicine Abroad
Response in PDF format.
Organization
[November 19, 2022 2:27 PM]
Indigenous Disability Canada
Response in PDF format.
Physician (including retired)
[November 19, 2022 12:44 PM]
Please just copy and paste the WHO conscience rights for medical practitioners. it's clear and simple and allows much more individual freedom in its wording and nature. The Family Physician knows the patient and family best. To hog-tie them with a series of "pronouncements from on high" does not help in the provision of healthcare.
Physician (including retired)
[November 18, 2022 2:24 PM]
The policy should include a statement that the College of Physicians and Surgeons of Ontario respects and supports the human rights of all the physicians and surgeons of ontario and a specific statement that describes how it implements that policy. There should also be a statement describing the steps that could be taken if an invidual physician or surgeon or a group of physicians and surgeons believe that the College of Physicians and Surgeons has violated their human rights.
Physician (including retired)
[November 18, 2022 1:24 PM]
Dear Colleague/s

The fundamental issue at stake in requiring objecting physicians to participate in MAiD against their will can be stated:

1. MAiD or medical euthanasia is not a morally neutral medical treatment, or one where benefits outweigh costs in all cases, therefore it is morally wrong to require physicians to recommend treatment that they consider to be harmful to their patients, even if they (appear to) request it.

2. Since this is regarded by some physicians as morally unjustifiable (on grounds of harm done to patients, to society, to conscience and to the medical ethic that forbids the deliberate taking of life as enshrined in the Hippocratic oath) those physicians should not be required to participate in any aspect of the process of MAiD which is a detailed process that includes referral, as much as the administration of lethal drugs.

In short, if someone asks me to push them off a bridge, and I refuse that should be the end of the matter. Your proposals would require me to get someone else to do the job, and then check to make sure I made it happen, and then punish me if I refuse to cooperate!

Active participation in MAiD is a clear violation of conscience for those physicians who object on moral grounds, at any stage of the process. The issue of harm to patients from non-participation is a moot point, since it clearly depends on each individual case. In some cases, a physician who objects may influence their patients to take a sober second thought and save their lives, and in many other cases patients would simply find another physician to refer them.

Thanks for your patience in reviewing my comments
Physician (including retired)
[November 18, 2022 10:59 AM]
Dear Colleague/s

My understanding is that the CPSO is proposing to set standards that effectively force physicians who are conscientious objectors to MAiD to make an effective referral, and to positively confirm that such as referral has been made; indeed that MAiD should be offered as a form of therapy in normal medical settings

It must be clear to the College that such a proposal represents a deep violation of conscience for the physicians involved. Furthermore it deliberately targets conscientious objectors by rubbing their noses in it, since physicians who refer without moral objection are not required to confirm an effective referral.

What is the point of acknowledging conscience if the rules you propose violate conscience? The idea that there will be needy patients who are prevented from taking part in MAiD by their physician is the only possible justification for these rules, but that is a theoretical scenario that seems very unlikely. Does the College have a shred of evidence that this is happening?

To those of us who believe that physicians should never deliberately take life, as a fundamental more of medical ethics, these proposals appear to amount to an all out war against the moral rights of individual physicians, as enshrined in this country's Charter of Rights and Freedoms

Furthermore, to frame the debate as though it were just about a few cranky off-beat physicians, a tiresome minority, is to forget the negative consequences of euthanasia on medicine and society at large. As Canada continues to operate this madness, more and more stories are emerging of the downsides of euthanasia. We know this from other countries such as the Netherlands, where infanticide is regularly practiced (for instance for children diagnosed with hydrocephalus after birth). Indeed there is a proposal before Parliament at present to extend MAiD to infants

Many thanks for taking my comments into consideration. My proposal would be to respect and protect the conscience rights of all physicians; those we do not wish to participate in MAiD should not be required to make or confirm a referral for their patients (as they can discover a referral route for themselves with ease, and sadly many physicians see no moral objection to MAiD) and should not be required to suggest MAiD as a medical option in their consultations with patients
Physician (including retired)
[November 18, 2022 10:41 AM]
Note: Some content has been edited in accordance with our posting guidelines.
Hello
 
My name is [redacted] and I am a family physician working in [redacted] Alberta with full scope of practice including a fair amount of palliative medicine.
 
I recently became aware of the proposed changes to the Ontario MAiD legislation and I wanted to express my concern especially regarding the opportunities for practitioners to conscientiously object. I see the obligation for conscientious objectors having to confirm that the patient was contacted by MAiD services, as distinctly different from other areas where we make referrals where one might object, namely in the circumstance of abortion. It is my understanding that a patient can self refer for this service, and so a physician's involvement is really minimal. I respect patient's right to choose, but I resent what appears to me to be discrimination for those conscientious objectors, when the same standard does not demanded of others who are more in favor of this service. I understand our society's want for more freedoms, and I truly question the necessity for Physicians' involvement in liaising this service. When access is not restricted to physician referral, I find conditions placed on a physician in this circumstance to be unnecessary and patronizing.
 
Thank you for your time.
Physician (including retired)
[November 17, 2022 7:50 PM]
Fundamentally disagree with the concept of anti-racism. I think in and of itself it is a racist concept. It is the same agitprop that informs white kids that they are innately and irrevocably racist and that black children are innately and irrevocably victims. It is an incitement To sectarian hatred. It is complete fancy as a theory much as is critical race theory iiself. It is born out of a need for the radical left to incite class warfare in one form or another.
Physician (including retired)
[November 17, 2022 7:05 PM]
Please include (if not done): no discrimination based on refusal of any medical treatment. Please also enshrine the CPSO's Consent to Treatment and Canada's Freedom of Choice in this document so no one will ever be coerced or forced to undergo any medical treatment they do not want.
Physician (including retired)
[November 17, 2022 7:04 PM]
we are already suffering badly from a severe doctor and nurse shortage. yet you are pushing very controversial gender politics onto many of us who just don't agree with all the political dogma on this. And you are pushing a very sizeable number of doctors and nurses to either quit or leave this jurisdiction. The numbers are too great for you to understand even though most of us are scared to express our moral views publicly within the current cancel culture. Florida just banned surgeries and chemical blockers on minors and many other jurisdictions are moving that way. These are no universal codes on these things even though you would like to pretend there are while denying undeniable facts of science and biology which we spent decades learning in school. Many physicians consider the underlying pathophysiology of what was until very recently called gender dysphoria to be similar to eating disorders. We don't enable minors with eating disorders. You are mixing ultra-left politics of the day into our profession without regard to the permanent damage you are causing.
Physician (including retired)
[November 17, 2022 6:04 PM]
My experience over 35 years of pracitce is that no one cares what I think
Organization
[November 17, 2022 2:25 PM]
Ontario Association for ACT & FACT
Response in PDF format.
Member of the public
[November 16, 2022 5:15 PM]
Note: The attached response was signed by 30 rabbis in the Greater Toronto Area (GTA).
Response in PDF format.
Physician (including retired)
[November 16, 2022 6:51 AM]
Important to note the recent updated INTERNATIONAL CODE OF MEDICAL ETHICS of the World Medical Association position on the issue of conscience. The CPSO should consider using this as guide:

"29. This Code represents the physician’s ethical duties. However, on some issues there are profound moral dilemmas concerning which physicians and patients may hold deeply considered but conflicting conscientious beliefs.

The physician has an ethical obligation to minimise disruption to patient care. Physician conscientious objection to provision of any lawful medical interventions may only be exercised if the individual patient is not harmed or discriminated against and if the patient’s health is not endangered.

The physician must immediately and respectfully inform the patient of this objection and of the patient’s right to consult another qualified physician and provide sufficient information to enable the patient to initiate such a consultation in a timely manner."

https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/
Organization
[November 07, 2022 1:33 PM]
Canadian Medical Protective Association (CMPA)
Response in PDF format.
Physician (including retired)
[November 01, 2022 9:28 PM]
Note: The attached response was signed by Indigenous representatives, including physicians, other health-care workers, and members of the public.
Response in PDF format.
Organization
[November 01, 2022 6:30 PM]
Physicians Together with Vulnerable Canadians
NOTE: During the consultation period, we received eight responses from individual respondents containing the following.
Response in PDF format.
Organization
[November 01, 2022 1:36 PM]
Professional Association of Residents of Ontario (PARO)
We found the draft policy to be complete and feel it provides useful guidance and the expectations are clear and reasonable. We especially appreciated how it provided specificity particularly around expectation for an effective referral.
 
The point form (question answer format) is very helpful. It would be even better if there is a summary page of all the questions for the reader to navigate / have a concise one pager with short answers.
 
We found his policy to be straightforward, and the Advice document is particularly helpful in addressing specific physician concerns in a way that is accessible to multiple parties. If this policy and Advice document will be available to the public, we would encourage that it be available in website, print, and audio to ensure accessibility to all parties.
 
We once again appreciate being included in the CPSO's consultative process.
Physician (including retired)
[October 20, 2022 3:35 PM]
This is an incredibly important update. The incorporation of antiracist and anti-oppressive principles makes the expectations both explicit and clear. Furthermore, that these recommendations are grounded in a human rights based approach.

Lines 27-33 are important and clear around what is expected of physicians in providing patient care. The incorporation of cultural humility (not making assumptions or stereotyping patients), cultural safety (providing care that is free of discrimination), anti-racism and anti-oppression are particularly important (identifying and challenging existing systemic oppression and racism within healthcare).

Lines 58-61 are also an important protection for physicians's rights to be free from discrimination or harassment by patients: "tell the patient that their request will not be accommodated if the physician believes that the request is discriminatory (e.g., racist, sexist, ageist, heterosexist, etc.) and determine whether it is safe and in both parties’ best interest to provide any non- emergent or non-urgent care required."

This update is a step in the right direction for the CPSO and is necessary given the medical profession's past contributions to injustices in Canada. I agree that incorporation of accountability mechanisms as well as in-line definitions may be helpful.
Physician (including retired)
[October 09, 2022 12:44 PM]
Can we get some clarification and assurance from the College what happens with all these comments? Have some recollection at time of prior consultation re fee increase that about a thousand docs wrote in to oppose and College went ahead with a fee increase anyway. Is this all just so that it can be said that consultation with physicians and the public was undertaken?
Physician (including retired)
[October 07, 2022 11:57 AM]
seems likely there will even more unintended consequences to this than usual!

see, for example https://www.commonsense.news/p/what-happens-when-doctors-cant-speak and https://jamanetwork.com/journals/jamaoncology/fullarticle/2780915 and many others

the young enthusiastic docs are likely to be the ones burdened [and burned] by all of this

Good luck!
Medical student
[October 05, 2022 10:35 AM]
With this document, Ontario is setting an example for equitable and welcoming healthcare! It will be uncomfortable at first and there is likely to be some hesitancy toward these policies. However, there is a need for this! A lot of people face discrimination and generally do not feel comfortable accessing healthcare. This document sets the standard for quality care in Ontario and will slowly shift the status quo. With the concepts of anti-oppression integrated, Ontario will become a positive example for high-quality healthcare for other provinces and countries to follow.
Physician (including retired)
[October 02, 2022 10:53 AM]
What about human rights of physicians?
Physician (including retired)
[September 30, 2022 10:58 AM]
"The spirit of the policy is clear." Are you sure? In America, anti-racism has been used as an excuse to provide preferential treatment in the job market, schools application, and even now medical wait times for specialist clinics or medical tests based on race.

Is this the spirit of the document? Is this the spirit of Canadian health care?

Should I have special same day appointments only for patients of a certain race? Should this be permitted or encouraged for doctors in Canada?

Should I have to write a patient's race down when I order a CT abdomen because I'm concerned they might have cancer so they can wait longer or shorter based on their race?
Physician (including retired)
[September 30, 2022 10:53 AM]
What specifically do you think doctors should be doing to be "anti-racist"? Do you believe the approach being used by anti-racists in America of providing preferential treatment and shorter wait times based on patient skin colour is for example a good idea? What will you tell your patients when they ask why their skin colour means a 4 month wait time for a CT scan instead of a 1 week wait time if it was a different colour, while they worry they may have cancer?

"To see what antiracism means, consider the antiracist pilot program that two Harvard Medical School professors announced last year at Boston’s Brigham and Women’s Hospital. They pledged to provide a “preferential admission option” for certain minority patients, requiring overt discrimination by skin color. Writ large, antiracism would embed this divisive and dangerous practice across all of health care. Patients could be denied or delayed treatment, not because of their medical needs, but because of their race."

https://www.bostonglobe.com/2022/09/18/opinion/antiracism-effort-health-care-would-itself-lead-bias/

Is this what you think the Canadian health care system should look like too?
Physician (including retired)
[September 30, 2022 10:48 AM]
Anti-racism has been used to provide preferential queues for patients on the basis of their races while waiting for medical referrals and tests. Is this something you endorse?

See for example:

https://www.bostonglobe.com/2022/09/18/opinion/antiracism-effort-health-care-would-itself-lead-bias/

The policy to provide individuals of a certain race preferential treatment over individuals over another race and a fast track access to a hospital program is linked there.

Is this the future of medicine in Canada you want to see? Telling your patients that if they have one skin colour they will be seen in a week but if another skin colour they will have to wait 2-4 month?

Which skin colours should get the preferential treatment and which ones should wait with potentially dangerous conditions longer instead?
Physician (including retired)
[September 30, 2022 10:43 AM]
I am not sure anyone here actually recognizes what "ANTI-RACISM" represents.

It is NOT non-discrimination. It is the institutional endorsement of ACTIVE DISCRIMINATION. This is not my opinion but clearly what it advocates for and how it has been carried out in the real world over the past few years (and this continues to be the case).

For example see the following examples of what ANTI-RACISM has led to in the news:

1) In Harvard, there is an ongoing lawsuit where Southeast Asian students were actively discriminated against in admissions because they scored too highly on tests:

"They contend in their lawsuit that Harvard systematically discriminates against Asian-American applicants in violation of federal civil rights law, by penalizing their high achievement as a group, while giving preferences to other racial and ethnic minorities. They say that Harvard’s admission process amounts to an illegal quota system."

https://www.nytimes.com/2020/02/18/us/affirmative-action-harvard.html

2) In medical universities that have incorporated "anti-racism," this has meant racist applications of scholarships based primarily on the race of each individual applying:

"In June, the organization filed five discrimination complaints against the US Department for Civil Rights alleging that the Florida College of Medicine, University of Minnesota Medical School, University of Oklahoma-Tulsa School of Community Medicine, University of Utah School of Medicine and the Medical College of Wisconsin were biased against white students because they only offered scholarships to minorities."

https://nypost.com/2022/09/29/upenn-doctor-anti-racist-policies-are-wrecking-american-medicine/

3) Most dangerously, in medical treatment systems where anti-racism has been adopted, it has led to separate wait queues for patients for tests and services based on their skin colours:

"To see what antiracism means, consider the antiracist pilot program that two Harvard Medical School professors announced last year at Boston’s Brigham and Women’s Hospital. They pledged to provide a “preferential admission option” for certain minority patients, requiring overt discrimination by skin color. Writ large, antiracism would embed this divisive and dangerous practice across all of health care. Patients could be denied or delayed treatment, not because of their medical needs, but because of their race."

https://www.bostonglobe.com/2022/09/18/opinion/antiracism-effort-health-care-would-itself-lead-bias/

Are these the specific intentions of this policy?

Does the CPSO wish for us to identify the races of our patients on referrals so they can get preferential or less preferential treatment on the basis of their races? If not, what exactly is intended?

The danger is that you don't actually spell any of this out, and this is exactly how "anti-racism" is being used. I am not sure if that is your intention. But racism to answer racism is never the answer.

Please provide a policy that works AGAINST racism and discrimination rather than one that institutionalizes it. Please protect patients against any such discrimination on the basis of their skin or other group factors. Please do not encourage the medical system to enact such discrimination actively instead.

Martin Luther King would be rolling around in his grave.
Prefer not to say
[September 30, 2022 10:28 AM]
How does one ascertain that another person has been sufficiently indoctrinated into a particular political or religious ideology? And if a person is found wanting in a particular political or religious ideology what action is undertaken to ensure sufficient indoctrination? I agree with the poster above that this a very post modern document. Are you sufficiently “ anti oppressional “ ? How are they going to tell if anyone is or isn’t anti oppressional? I would go further than calling it a post modern document. This is very dystopian or even orwellian. They’re essentially attempt to coerce the membership of the CPSO into adopting “woke” ideology. There is nothing wrong with enforcing human rights laws and educating people about discrimination, bias and cultural humility. This document is much more than that. The document is
simply a clumsy attempt to indoctrinate physicians in a woke ideology. This is essentially a left wing progressive version of McCarthyism. “ Are you now, or have you ever been, a member of the Communist party?” “ Are you sufficiently anti oppressional?” The house un- american activities committe or the CPSO would like to know? If somebody , a patient or other cpso member, feels that your exhibiting subversive political behaviour they’ll be able inform on you so that you can be publicly censored for lacking the appropriate political ideology.
Physician (including retired)
[September 29, 2022 1:46 PM]
This policy is helpfully making explicit some of the expectations of physicians providing care in Ontario, based on the Ontario Human Rights Commission - while CPSO processes are separate we are still beholden to the OHRC. The advice document is particularly helpful in clarifying our responsibilities.

In terms of the above feedback suggesting that it will be difficult to tell whether patient requests are discriminatory, I would say that most of the time the nature of these requests is relatively clear, and for those that are not clear, as the advice document says, we must use our professional judgment, just as we do every day!

I appreciate the specific inclusion of the need for incorporating cultural safety, anti-oppression, and anti-racism in our practice, and given that we all need to work on incorporating these frameworks it makes sense that there are not clear indicators of how these are incorporated in the policy. The spirit of the policy is clear, and if there is a complaints process then physicians can explain how they incorporate these frameworks in their practice in that process.

This is a much-needed policy and much appreciated!
Physician (including retired)
[September 29, 2022 11:41 AM]
I like it. Just one comment on 4b and placing the burden on physicians to find a physician who speaks their language or other.
Member of the public
[September 28, 2022 6:24 PM]
Note: Some content has been edited in accordance with our posting guidelines.
We need to go back the the Hippocratic Oath: first do no harm.
 
I have been supportive of the right to die. However, now mentally disabled people are being fast-tracked into this, it has gone too far.
 
[redacted]
 
Countries that pioneered gender affirmation (Finland, Sweden, UK, etc.), are moving away from fast-track use of puberty blockers because it does more harm than good, and there are now hundreds of lawsuits ramping up as a result. Why is Ontario so far behind? [redacted]
 
---------
 
I also agree with the previous 2 respondents, there is far too much identity politics and postmodern ideology in this document. Anti-racism/anti-oppression sound good, until you understand what that really means. Anti-racism, as defined by Kendi and others, as requiring us to be in a perpetual awareness that racism is everywhere, and we should inject race into everything. It is the opposite of the Martin Luther King approach. See: https://newdiscourses.com/tftw-antiracism/
Physician (including retired)
[September 28, 2022 2:59 PM]
Many older physicians will recall that - at least until the current Registrar was hired - the College was by far the biggest perpetrator of aggression against physicians, and many have been left afraid, traumatized, mistrusting, demoralized ... or dead. See for example https://www.theglobeandmail.com/news/national/gentle-dr-hsu-and-the-audit-that-haunted-him/article746626/ and https://www.theglobeandmail.com/news/national/controversial-audit-of-billings-leads-mds-to-despair-death/article742908/ And sadly there were other witch hunts in various other College programs which led members to scale back practices or leave entirely.
The College's recent focus on universal human dignity, human rights, fairness and civility would be much more persuasive if it publicly examined its own chequered past and made amends to the profession and to the physicians, patients, citizens and taxpayers of Ontario who silently bore the enormous cost of past atrocious misdeeds that have never been properly examined and acknowledged.
An appreciation of human rights - and truth and reconciliation - starts at home, CPSO!
Physician (including retired)
[September 28, 2022 7:55 AM]
While it is encouraging to read item 32 b. incorporating cultural humility, cultural safety, anti-racism, and anti-oppression into their practices , and to see, in particular, cultural safety, anti-racism and anti-oppression named, which is an important first step, I offer the following observations.

1. It is problematic that anti-racism and anti-oppression are not explicitly defined in this document. Discrimination is clearly defined as it was the previous version. But not defining it clearly in this document can have a mitigating effect on the stated objective -- to embed anti-racism and anti-oppression. Including a robust definition (up front) in the main document would further this goal. Granted there is a hyperlink to EDI definitions, one wonders how probable it is for one to click that link. By one of contrast, in the policy I have attached on ableism and discrimination, ableism is explicitly defined and then further elevated (by these policy makers) to be akin to racism. And the ableism policy is a whopping 99 pages compared to the brief human rights policy we are contemplating here. In the matter of scale and proportion there is no contest. Ableism, in addition to other 'isms' trump racism. But this is a victory nonetheless.
2. A second concern, however, is that 32 b has no accountability link. Other behavioral violations have a link with explicit consequences. In this current draft, 32 b has words but no apparent mechanism, process, or metric to assess compliance of the expected behavior. How will one assess if a physician is, in fact, incorporating these approaches in his/her/their practice? How will this be measured is this new human rights draft?
3. As a point of information, the reference I site below has an excellent definition of anti-racism, anti-oppression, and cultural safety. Should you be able to embed the definitions of these terms up front in the next revision of this draft, you may considering the reference below as an excellent resource.

Data Standards for the Identification and Monitoring of Systemic Racism: Glossary [Internet]. Government of Ontario. [cited 2022 Sep 1]. Available from: https://www.ontario.ca/document/data-standards-identification-and-monitoring-systemic-racism/glossary

Keep up the great work. It is a step forward, and time to push for more progress.
Physician (including retired)
[September 27, 2022 8:03 PM]
The document looks balanced, fair to all, and appropriately worded to be unambiguous. It’s advice statements provide good guidance without being heavy or prescriptive. It does oblige physicians to work on behalf of patients, regardless of the patients’ individualities and situates the patient above the provider when there could be a "tie of rights"
Physician (including retired)
[September 27, 2022 1:27 PM]
Note: Some content has been edited in accordance with our posting guidelines.
It seems the individuals who wrote this proposal were not actually interested in providing clear, practical, evidence-based, and useful professional guidance and professional standards for doctors to follow. Unfortunately, this policy reminds me very much of the perhaps well-intentioned but horribly and impractically conceived "Social Media" proposal that was made last year. That policy read much more like a foreign authoritarian government's Online Censorship bill, providing endless routes for patients to make spurious and malicious complaints while providing doctors with no way to defend against these, as no specific or clear parameters for judging offenses were provided.
 
You ask: "Are the expectations set out in the draft policy clear and reasonable?" Unfortunately, in many regards, these documents are not even close to being clear, reasonable, or useful. They would need a lot of work to improve in order for them to reach this expected standard.
 
The first major problem occurs on line 32: "Physicians MUST incorporate cultural humility, cultural safety, anti-racism, and anti-oppression into their practices."
 
What exactly do each of these things represent and specifically what MUST we do in our day to day medical practices to incorporate them?
 
[redacted]
 
Your advice documentation provides no clarification and only introduces more confusing and unclear terms like "racialized people." What exactly is a "racialized" person? I I have brown skin. Am I "racialized"? On what basis and what does that mean? Are some people more "racialized" than others? Frankly I find such a term personally offensive and discriminatory, as I do not accept being judged on the colour of my skin in any regard, by the CPSO or anyone. The CPSO policy seems to endorse this type of racial discrimination and segregation of patients based on our skin colours. Is this the intent? [redacted]
 
The same problem occurs with the term "anti-oppression." What specifically does this mean in a practical daily medical sense? [redacted] How is this judged or audited in my practice? [redacted]
 
Further deepening these problems is the line on 17: "Rules, practices, or procedures may appear neutral but have the effect of disadvantaging certain groups of people. Discrimination is best identified by those who experience it given that there is a difference between intent and impact."
 
This policy seems to imply that the CPSO is not willing to define any objective standards whatsoever for what qualifies as discrimination. How do you intend to enforce a policy where there is no objective standard for what constitutes professional misconduct? Is this, yet again, like the prior social media proposal, another "all doctors are guilty until proven innocent" policy?
 
You have stated clearly you believe discrimination is "best defined by those who experience it," implying that any individual who makes a complaint on any basis has better standing to define the supposed crime than the CPSO who is expected to adjudicate the complaint or the doctor who is accused. Imagine a legal system that worked this way.
 
Imagine police and courts stating, "Any average individual in the population is in a better position to tell if a crime happens than we are. We defer to them as we are not capable of judging it." No. This would not work even for one day. The police and courts MUST be the BEST STANDARD for defining if a crime happens. If any average person claims that a crime occurs, it is up to the police and courts to define if that violation truly occurred. Similarly it is the CPSO's job to determine if a policy violation occurs, not the patient.
 
The CPSO seems to imply in this policy that it is incapable of performing this task and actually evaluating complaints on the subjects it raises. Who is the authority on if discrimination has truly occurred? If it is not the CPSO who is meant to regulate this (according to this policy), do we need a new regulatory body that actually has the competence and can provide the clarify of policy to evaluate this objectively?
 
How does one prove that discrimination did not in fact occur if you yourself claim you cannot judge whether it occurs or not? How does this help or enable a doctor to clear their name if a spurious or malicious claim is made? Who is in a position to evaluate that? If the CPSO is not capable of making such an analysis, what process is a doctor meant to use in order to escape such a malicious or spurious complaint? Would it not have been simpler and better to say something like: "Doctors must provide non-discriminatory care that provides equal health care to all patients regardless of their race, gender, etc."? Is this not actually the intention of this document? If that is not the intention, again I seek clarification on which manner of discrimination we are supposed to be endorsing in order to be sufficiently "anti-racist" and "anti-oppression."
 
[redacted] I have only ever provided non-discriminatory care. It is not in my training to actively discriminate for or against patients on any basis like gender/race/religion/etc as this policy requests.
 
Another problem occurs at line 35: "Physicians MUST NOT express personal moral judgments about patients’ beliefs, lifestyle, identity, or characteristics or the health services that patients are considering." Is this specific to one circumstance or all circumstances? I have known and cared for patients who have actually murdered other individuals in their rage or who have performed other horrific acts. Am I prohibited from explaining to an antisocial, psychopathic, or addicted individual that drunk driving is morally wrong because although they didn't kill someone the last time, any time they do someone might die, and that would be an awful thing to occur?
 
Similarly, if I have a patient who discusses that they are considering tricking their partner into a pregnancy by manipulating the contraception they or their partner are using, am I not allowed to explain the moral issues that this raises? I have actually had this conversation with several patients because they have felt free to talk to me about it (for example, removing IUD without telling partner to get pregnant). In those conversations I raised the moral pros and cons of such actions and explained that while it is their choice, in my opinion, good honest communication is best, and to my knowledge, they all came to agree with this perspective.
 
Am I prohibited from providing such moral advice on these and other issues going forward? Morality and what is right or wrong in any given situation enter many discussions as many of my patients come to me for advice. Morality around workplace conflict is a common subject patients raise as well. Similarly, many patients ask me for advice about the morality of their actions in child custody cases. Which specific moral advice am I allowed or prohibited to provide?
 
Can the CPSO actually define the problem you are seeking to rectify in SPECIFIC and CLEAR terms that do not capture such circumstances I described (if you agree I am still permitted to provide such advice and moral guidance to patients who seek it from me)? Or am I to tell all patients I cannot provide any advice on any subjects relating to personal morality? All morality is subjective and thus all morality is personal. My patients ask this of me regularly. Should I be telling them this is banned by the CPSO and I cannot comment or advise them as they request?
 
I am next completely puzzled by line 58: "Where a patient requests to receive care from a physician with a particular social identity (e.g., race, ethnicity, culture, sexual orientation and/or gender identity, spiritual/secular/religious beliefs, etc.), physicians MUST tell the patient that their request will not be accommodated if the physician believes that the request is discriminatory (e.g., racist, sexist, ageist, heterosexist, etc.) and determine whether it is safe and in both parties’ best interest to provide any non-emergent or non-urgent care required."
 
Exactly what does this mean? You say just above this section that we must accommodate referrals to different doctors on any basis the patient asks for if the patient wants a doctor of a given race/gender/culture/ethnicity/religion. But then immediately you tell us we must also refuse if this request is discriminatory.
 
How does this make any sense? Which specific requests are we supposed to accommodate and which ones are we supposed to refuse? Are there specific races or genders patients are allowed to request and others they are not? Which ones are they allowed to request and which ones are we intended to refuse? How does a doctor know if they themselves are being discriminatory by refusing or accommodating a referral made on the basis of race for example? Is it based on the colour of the request? If so, which colours of doctors are permitted for patient request and which are not?
 
You give one example of when such a request is appropriate: "a patient would like to receive care from a physician who speaks the same language to facilitate communication," but this example has nothing to do with race/gender/culture/ethnicity/religion and is instead a simple practical one. Obviously patients want doctors who speak their languages. That goes without saying.
 
Can you give examples of when it is appropriate or inappropriate for a patient to request to only see doctors of a certain race/gender/culture/ethnicity/religion?
 
Your policy seems to imply there are such circumstances where we must accommodate these requests and others we must refuse but does not define them. Currently in my practice, the only such accommodations I provide or commonly encounter are for language and gender with sensitive bodily exams. I have never had a patient request not to see me or see another doctor based on skin colour, but your policy seems to imply that valid reasons for doing so exist. Can you clarify what those valid conditions would be?
 
The CPSO asks: "Are there issues not addressed in the draft policy that should be?" The main problem with this policy is a complete lack of clarity on any of the above points. The policy talks out of both sides of its mouth. It does not provide clear or useful advice to doctors.
 
CPSO policies are the defined law doctors must abide by or face professional misconduct claims and the loss of our licenses. It is not optional for them to be clear and concrete. Violations must be carefully written to encompass only the intended circumstances and not provide endless leeway for selective application of those rules based on the biases of CPSO regulators.
 
We spend a decade in school and decades more in our careers to try to provide the best care for our patients. It is our expectation that if a policy is written which may allow someone to remove our medical license by the CPSO, this should be a carefully worded policy based on objective and provable conditions which will allow us to defend against spurious and malicious complaints and prove when we are or are not in compliance.
 
Please provide a policy that is actually clear and provides objective standards by which violations can be judged and defences against spurious and malicious complaints can be made. Currently this policy is completely lacking in these regards and is more dangerous to everyone than it is helpful.
Physician (including retired)
[September 27, 2022 10:33 AM]
It seems the CPSO has decided it wants to regulate identity politics. Its important to educate physicians about discrimination but I think the CPSO has lost the distinction between regulating a profession and indoctrination of progressive political ideology. Educating physicians around concepts like “cultural safety” is important but you don’t want to placed in a situation where your enforcing a particular political ideology through regulation. This is a fool’s errand.